Some people under the age of 65 can be eligible for Medicare with a qualifying disability or End-Stage Renal Disease (ESRD). But can people under age 65 qualify for a Medicare Advantage plan?
The answer is yes — under certain circumstances, you may be able to enroll in a Medicare Advantage plan before turning 65. Let’s review what those circumstances can include and how and when you may be able to apply for a Medicare Advantage plan under 65.
To be eligible to apply for a Medicare Advantage plan prior to turning 65 years old, you must first qualify for Original Medicare. This typically requires that you meet the following criteria:
Note: If you receive disability benefits because of Amyotrophic Lateral Sclerosis (ALS), the 24-month waiting period is voided and you will be automatically enrolled in Medicare Part A and Part B the first month that you receive disability benefits.
The Social Security Administration — not Medicare — determines whether or not you meet the requirements for disability payments. It is that determination that in turn can make you eligible for Medicare. Qualifying for disability means that you meet Social Security’s definition of disability, which reads:
“The inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”
A “medically determinable physical or mental impairment” is defined as:
“An impairment that results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques. The medical evidence must establish that an individual has a physical or mental impairment; a statement about the individual’s symptoms is not enough.”
The qualifying illnesses that affect eligibility for Medicare Advantage differ slightly from that of Original Medicare.
Medicare recognizes End-Stage Renal Disease (ESRD) as a qualifying disability for enrollment. Many Medicare Advantage plans, however, generally don’t allow people with ESRD to enroll. An exception is a type of Medicare Advantage plan called a Special Needs Plan.
A Medicare Special Needs Plan (SNP) is a type of Medicare Advantage plan that limits membership to people who live with specific diseases or characteristics. The benefits, provider choices and drug formularies tied to the plan may then be tailored to meet the specific needs of the members they serve.
Special Needs Plans differ from other Medicare Advantage plans in that they must provide coverage for prescription drugs. Other types of Medicare Advantage plans may or may not provide prescription drug coverage. There may be Special Needs Plans specifically for people with End-Stage Renal Disease available where you live.
Membership for a Special Needs Plan may also be extended to people who reside in nursing homes and other facilities, people who require at-home care and people who are eligible for both Medicare and Medicaid. If eligible, you may enroll in an SNP at any time.
If you are under the age of 65 and are eligible for Medicare Part A and Part B, you can apply for a Medicare Advantage plan during several different enrollment periods, depending on your situation.
If you qualify for Medicare because of a disability, your Initial Enrollment Period for a Medicare Advantage plan will consist of a 7-month period that begins three months before your 25th month of receiving disability benefits, includes your 25th month of receiving benefits and continues for another three months after your 25th month of receiving benefits. In other words, your Initial Enrollment Period will last from your 22nd month through your 28th month of receiving disability benefits.
The Open Enrollment Period (sometimes called the “Annual Election Period”) runs every year from Oct. 15 to Dec. 7. During this time, anyone with Medicare Part A and Part B (including those under 65) can apply to enroll in a Medicare Advantage plan. Those who are already enrolled in a Medicare Advantage plan may use this period to switch to a new plan or drop their current plan and return to Original Medicare (Part A and Part B).
The coverage for any enrollment actions taken during this period will begin Jan. 1.
There is also an opportunity for people under 65 who are already enrolled in a Medicare Advantage plan to change to a different plan or drop their Medicare Advantage plan coverage entirely.
A Special Enrollment Period may be granted at any time throughout the year under certain circumstances. These circumstances can include events like moving to a new address outside of your current plan’s coverage area or moving in to or out of a skilled nursing facility or long-term care hospital. There can also be some other situations that qualify you for a Special Enrollment Period.
Medicare.gov provides a full list of Special Enrollment Period qualifications.
Lastly, there is also a 5-star Special Enrollment Period, in which a Medicare Advantage plan holder may switch to a new plan that carries a 5-star rating as determined by Medicare. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. This enrollment period lasts from Dec. 8 to Nov. 30 of the following year, but may only be utilized once per enrollment period.
People under the age of 65 who qualify for Medicare Advantage also qualify for several Medicare cost-assistance programs.
Medicare Savings Programs are available through the Qualified Disabled and Working Individuals Program, which helps pay Medicare premiums for working disabled people.
Medicaid can be used by people under 65 to pay for their Medicare Advantage costs.
Supplemental Security Income (SSI), which is different from Social Security Disability Income, pays benefits to disabled people who can in turn use those benefits to help pay for Medicare Advantage costs.
By law, Medicare Advantage plans must offer at least the same benefits as Medicare Part A and Part B. Some Medicare Advantage plans may offer additional benefits that are not covered by Medicare, such as dental care, vision care, hearing care, prescription drugs and more.
Someone with a disability may find that these additional benefits fit their health coverage needs. For instance, if a Medicare Advantage plan provides coverage for the type of prescription drug required of someone with a disability, that person might consider enrolling in that plan.
A person under 65 with a qualifying disability may have additional health coverage needs related to their disability, such as coverage for vision or hearing care. But because these areas are not covered by Part A or Part B, a Medicare Advantage plan that does offer these benefits might be seen as a fitting option.
2012 data shows that 31 percent of Medicare beneficiaries under the age of 65 had five or more chronic conditions, and 59 percent self-reported their health to be in either poor or fair shape.1 Medical care for some of these chronic needs could potentially be better covered under a Medicare Advantage plan than with Original Medicare.
Some Medicare Advantage plans may feature different deductibles and cost-sharing measures than Original Medicare, which could make those plans more cost-effective when used in high volumes. Consider that the average Medicare spending for an individual under the age of 65 was $13,098 in 2014, which is considerably more than the $9,972 per-person average for Medicare beneficiaries who are over the age of 65.1 Considering this data, a Medicare Advantage plan with lower deductibles, out-of-pocket maximums or coinsurance costs could potentially be a good fit for a Medicare beneficiary under age 65.
It’s also important to note that Medicare Supplement Insurance (also called Medigap) may not always be as accessible to people under age 65. Medigap plans can help cover some of the out-of-pocket costs associated with Original Medicare, such as copayments and deductibles. Not every state offers these plans to people under 65, and even when they do, costs can be higher and enrollment can be more restrictive. In 2012, just 2 percent of Medicare beneficiaries under the age of 65 had a Medigap plan, compared to 27 percent of beneficiaries under age 65 who had a Medicare Advantage plan.1
Each Medicare Advantage plan carries its own coverage area, benefits, costs and other plan features. Luckily, you don’t have to go through the enrollment process alone.
Contact a licensed insurance agent today to find a Medicare Advantage plan that fits your specific health care needs. You can compare quotes from insurance carriers in your area, with no obligation to enroll.
1 Cubanksi, Juliette; Neuman, Tricia; Damico, Anthony. Medicare’s Role for People Under Age 65 with Disabilities. Aug. 12, 2016. Kaiser Family Foundation. Retrieved from https://www.kff.org/medicare/issue-brief/medicares-role-for-people-under-age-65-with-disabilities.