Having Social Security Disability Income (SSDI) and Medicare exempts you from the penalty for not having health coverage under the healthcare law. You cannot substitute or enhance your Medicare coverage with a Marketplace plan.

If a disability or chronic illness prevents you from working, federal programs like Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) can provide crucial support. Alongside monthly benefit payments, these programs offer health insurance coverage. 

While some recipients may need to fulfill additional requirements and submit applications for healthcare coverage, the ultimate outcome is access to free or low-cost insurance for you and possibly your family.

What insurance Do You Get With Social Security?

Social Security provides health insurance coverage through two main programs: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). While both programs offer monthly benefit payments to disabled individuals, SSDI typically includes Medicare coverage after a waiting period. 

On the other hand, SSI recipients may be eligible for Medicaid, providing essential healthcare coverage. The details and eligibility criteria can vary; applicants may need to fulfill additional requirements to access these insurance benefits.

What Is Medicare?

Medicare is a federal health insurance program primarily designed for individuals aged 65 and older but also covers specific younger individuals with disabilities. The program consists of different parts, each providing specific coverage:

  • Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
  • Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and some home health care.
  • Part C (Medicare Advantage): A private insurance plan that includes coverage from Part A and Part B, often with additional benefits.
  • Part D (Prescription Drug Coverage): Provides prescription drug coverage through private insurance plans approved by Medicare.

Medicare operates on a fee-for-service model, where beneficiaries can choose their healthcare providers. While Part A is generally premium-free for eligible individuals, Parts B, C, and D may involve premiums, deductibles, and co-payments. Additionally, beneficiaries can opt for supplemental coverage (Medigap) to help with out-of-pocket costs.

Medicare Premiums And Deductibles in 2023

Plan Premium  Deductible
Medicare Part A $0 for most people $1,600 per benefit period
Medicare Part B $164.90 for most people but higher if your annual income exceeds $97,000 $226 per month, but then you’ll still pay 20% of the cost for some services
Medicare Part C Varies by plan, can change yearly Varies by plan, but once you hit your out-of-pocket-max, the plan covers 100% of covered services
Medicare Part D Varies between plans and depends on your income Varies by plan and based on your pharmacy

How Does Medicaid Work?

Medicaid is a joint federal and state program that provides health coverage to eligible low-income individuals and families. The program is administered by states within federal guidelines and offers a wide range of health services. 

  • Eligibility: Eligibility for Medicaid is determined by income, household size, disability, and other factors. States have flexibility in setting their own eligibility criteria within federal guidelines.
  • Application: Individuals can apply for Medicaid through their state’s Medicaid office or online. Eligibility is typically determined through an application process that involves income verification and other documentation.
  • Covered Services: Medicaid covers many health services, including hospital and doctor visits, prescription drugs, preventive care, mental health services, and long-term care. States may also offer additional services beyond the federally mandated ones.
  • Managed Care: Some states use managed care organizations (MCOs) to deliver Medicaid services. In managed care, beneficiaries receive services through a network of healthcare providers.
  • Cost-Sharing: While Medicaid is designed to be affordable for low-income individuals, some states may require beneficiaries to pay small co-payments for certain services. However, these co-payments are generally minimal.
  • Expansion: The Affordable Care Act (ACA) allowed states to expand Medicaid eligibility to include more low-income adults. Not all states chose to grow, leading to variations in Medicaid coverage nationwide.
  • Dual Eligibility: Some individuals qualify for both Medicaid and Medicare. These “dual-eligible” individuals receive assistance with Medicare premiums, cost-sharing, and coverage gaps.

How To Get Health Insurance On SSDI?

While SSDI benefits offer Medicare coverage, there’s typically a 24-month waiting period before it becomes accessible. However, exceptions exist for individuals with specific conditions like amyotrophic lateral sclerosis (ALS), end-stage renal disease, or those on the compassionate allowance list, potentially shortening the waiting period.

How To Get Health Insurance On SSI?

If you qualify for SSI, many states automatically enroll you in Medicaid. Your SSI application is the Medicaid application, ensuring approval grants access to both benefits. However, a few states may necessitate a separate Medicaid application, with eligibility criteria aligning with SSI or potentially having additional requirements.

Health Insurance On Long-Term Disability

If you have a long-term disability plan, your best choice for health insurance may be private coverage, though it comes with its costs. Private health insurance can be a viable option, especially if your long-term disability plan lasts two years or more. Additionally, Medicaid could be an alternative for those with lower incomes, subject to state-specific eligibility criteria.

For those eligible, Social Security Disability Insurance (SSDI) provides another avenue. Some private plans may require applicants to apply for SSDI if their medical condition is anticipated to keep them out of work for more than a year. 

SSDI offers monthly benefit payments and Medicare coverage, contingent on providing medical evidence supporting a one-year or longer duration of the disabling condition. Medicare coverage will cease if your health improves, leading to a return to work.

Health Insurance On Short-Term Disability

If you’re on private short-term disability, securing a private health insurance plan is the primary choice. Employer-sponsored disability plans may allow continued coverage under their insurance during recovery. For California, Hawaii, New Jersey, New York, and Rhode Island residents, state short-term disability benefits are available, though they don’t include health insurance. (Learn more on how short-term disability works?)

Medicaid is an option for those with income below a certain threshold or those aged 65 and older. Workers’ compensation can provide wage replacement and medical coverage for work-related injuries or illnesses. (Learn more on what is workers compensation law?)

If your medical condition prevents work for a year or more, applying for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) is recommended, catering to different work histories and income levels.

Need Help With Applying For Benefits? Contact An Attorney

A Social Security Disability Lawyer can significantly aid in the disability benefits application process by ensuring accurate and thorough documentation of your disability, helping navigate complex legal requirements, and presenting a compelling case to improve your chances of approval.