If you think that Medicare is health insurance for America’s senior citizens, you’re only half right. It also covers essential healthcare services for individuals with certain disabilities, regardless of age.
More than providing healthcare coverage, Medicare is a vital component of America’s social safety net. Many Medicare recipients are living with disabilities and chronic health conditions, trying to care for themselves and live on modest fixed incomes. A quarter of all Medicare beneficiaries had incomes of less than $21,000 per person in 2023.
By providing what every citizen needs—affordable care to ensure health and wellbeing—Medicare helps to alleviate the burdens (financial, emotional, and physical) for recipients, as well as their families and caregivers.
What Is Medicare and Who Is It For?
Medicare was first enacted in 1965 as Health Insurance for the Aged under the Social Security Act, providing health coverage to almost all individuals aged 65 or older. In 1972, Medicare eligibility expanded to individuals under age 65 with long-term disabilities and End-Stage Renal Disease.
Today, Medicare is administered by the Centers for Medicare and Medicaid Services (CMS), part of the U.S. Department of Health and Human Services (HHS), providing health insurance coverage and medical benefits to individuals that are aged 65 and older and those with certain disabilities.
This coverage includes the two parts of the government-funded and managed Original Medicare:
Medicare Part A: Hospital Insurance providing inpatient hospitalization coverage, including hospital admittance, skilled nursing facility care, hospice care, and some home health care services.
Medicare Part B: Medical Insurance covering typical healthcare services (preventive care and screenings, doctor visits, lab work, outpatient, and ambulatory services) at any hospital, doctor, or provider who accepts Medicare.
Eligible Medicare beneficiaries then have the option to sign up for additional “parts,” such as coverage for prescription drugs (Medicare Part D) or to choose a comprehensive Medicare Advantage Plan (also known as Medicare Part C), which encompasses Part A, Part B, Part D, and additional health benefits like vision and dental. These are offered by private insurance companies, with Medicare paying the private insurer to cover and administer the healthcare benefits.
There are some differences in becoming eligible for Medicare based on medical conditions/disability versus age.
Age-Based Eligibility
Most Medicare recipients are eligible based on their age. Individuals aged 65 and older can take advantage of Medicare benefits by enrolling during the Initial Enrollment Period, which begins three months before their 65th birthday month, includes the birthday month, and continues for three months after their birthday month.
Medical Disability Eligibility
People under the age of 65 can qualify for Medicare if they are receiving disability benefits, either from Social Security Disability Insurance (SSDI) or Railroad Retirement Board (RRB). Individuals must be receiving these disability benefits for a minimum of 24 months to be eligible. Then, they are automatically eligible to enroll in Original Medicare Parts A and B. Additionally, those with End-Stage Renal Disease (permanent kidney failure) or ALS (Lou Gehrig’s Disease) are eligible for Medicare as soon as they start receiving disability benefits, or if they are the spouse or dependent child of an individual eligible for disability benefits.
Individuals eligible for a Medicare Advantage plan due to a medical disability have the option to enroll in either a Chronic Special Needs Plan (SNP) or a Core Advantage Plan, depending on which plan best meets their medical needs. Chronic SNPs often provide enhanced benefits tailored to specific chronic conditions, though they may offer fewer benefits in other areas. Conversely, Core Advantage Plans typically provide a more comprehensive range of benefits that can meet the overall medical needs of individuals with chronic conditions.
How Medicare Improves Health Equity and Financial Stability
Most age-eligible Medicare recipients qualify for premium-free Part A hospitalization coverage, as they’ve already paid by working and paying Medicare payroll taxes for 10 years or more. Anyone eligible for Social Security disability benefits is automatically covered by Part A, premium-free.
For Part B medical insurance coverage, Medicare pays 80% of healthcare costs with individuals responsible for the remaining 20%. The Part B premium, deductible, and coinsurance rates are set annually, based on income according to the Social Security Act. For 2024, the monthly premium is $174.70, with the annual deductible being $240.
Even with these lower set rates, many Medicare recipients can still face overwhelming healthcare costs. Medicare households spend a larger share of their total budgets on health care than non-Medicare households, and 36% of Medicare beneficiaries say they’ve had to delay medical care, doctor appointments, or filling prescriptions because of cost, according to a Kaiser Family Foundation survey.
There are four Medicare Savings Programs, each with different monthly income limits, eligibility criteria, and covered costs and services. To qualify for any of these programs, individuals must meet specific asset and income requirements, which vary by state due to differences in the cost of living.
Qualified Medicare Beneficiary (QMB) Program: Helps the lowest income individuals pay their Part A premium and Part B premium, deductibles, coinsurance, and copayments.
Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps to pay for the Part B premium only.
Qualifying Individual (QI) Program: Provides the same Part B premium assistance as the SLMB Program but at a higher income limit.
Qualified Disabled Working Individual (QDWI) Program: Helps those with Medical Disability-Based Eligibility who are still working pay their Part A premium.
There is also a Part D low‑income subsidy that helps recipients pay their Part D premium and lower the cost of prescription drugs.
By ensuring universal access to vital health services and preventative care at predictable, set costs, Medicare is improving health equity and financial stability for Americans with the greatest healthcare needs. They receive care essential for their wellbeing, regardless of income or employment status and with assistance that can help them avoid financial hardship due to medical expenses.
The Wandacare Team is here to help you and your loved ones claim your Social Security and Medicare benefits to get the quality healthcare you need. We’ll guide you through the process of filing for your benefits and enrolling for Medicare with the Social Security Administration.
