Overview

Signing Up for Medicare

There are different ways to get Medicare. For people with disabilities, Medicare eligibility is based on receiving Social Security Disability Insurance (SSDI) or Childhood Disability Benefits (CDB). These are government programs that provide income for people who can’t work because of a disability. So, when you can’t work because of a disability, SSDI provides income and Medicare provides health insurance. For more information on SSDI, see DB101’s SSDI program description.

The Two Year Waiting Period

When you apply for SSDI, Social Security figures out the day that your disability began. You’ll start getting a benefit check from SSDI five full months after that date. Once you start receiving SSDI payments, you generally have to wait two years before getting Medicare.

For example, if your date of disability is June 15, 2010, your first SSDI check will be for December 2010 (five full months after your date of disability). And your Medicare benefit will begin in December 2012 (24 months after you receive your first SSDI benefit check).

Illustration: Medicare's 24-month waiting period

During the waiting period you may be able to get help paying for medical costs either through:

The only exceptions to the two year waiting period are if you have Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease) or End Stage Renal Disease (permanent kidney failure).

The two year waiting period also applies to Childhood Disability Benefits (CDB).

Getting Medicare through SSDI: Enrollment Options

In most cases, when you get Medicare because of SSDI or CDB eligibility, you’ll automatically be signed up for Original Medicare (see details below). You’ll have to decide:

Original Medicare

How it Works

If you get Medicare through Social Security Disability Insurance (SSDI) or Childhood Disability Benefits (CDB), you are automatically signed up for Original Medicare. You’ll get a Medicare insurance card when your Medicare benefits start, and you’ll be signed up for Medicare Part A Hospital Insurance and Medicare Part B Medical Insurance.

With Original Medicare, you can go to any hospital or doctor that accepts Medicare and is taking Medicare patients. Medicare comes up with an amount that it thinks is reasonable for a provider to charge for a service. It will help pay that amount for things that it thinks are reasonable and necessary.

What You Pay

Most people do not have to pay anything to get Part A (since you've already paid for coverage with your payroll taxes). Part B, on the other hand, requires you to pay a monthly premium, which is taken out of your SSDI check. In 2019, the premium for Part B is $135.50 or a bit less, depending on your situation.

Because Part B has a premium, you can decide not to keep Part B coverage, although two things are important to keep in mind about declining Part B:

  • If you decline Part B at first, and then want to sign up for it later, you may have to pay a penalty.
  • You might qualify for help with paying for the premium and other Part B costs. See DB101's section on Part B for more information on enrollment, premiums, and declining Part B coverage.

For certain Part A and Part B services, you'll pay a certain amount (a deductible) before Medicare will begin to help pay. You may also have to pay a certain amount (a copayment) or a percentage (coinsurance) for the service before Medicare will begin to help. If you get a service that Medicare doesn’t cover, you will have to pay for it yourself, unless you have other coverage.

DB101's sections on Medicare Part A and Part B provide more details on what services Medicare will help pay for and what portion of the bill Medicare will pay.

If you want services that Original Medicare doesn't help pay for, you can pay out of pocket for those services. In this situation, some doctors may ask you to sign a private contract, which means that you agree that Medicare won’t help pay for any services you get from that provider.

Before signing a private contract, make sure that you understand what it means. If you need help understanding it, call the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222.

Appeals

You may think that Medicare should have helped pay for a service that they didn't help with, or that they should have paid more than they did. When you disagree with the amount that Medicare helped pay, you can file an appeal.

How will I know how much Medicare paid for my medical expenses?
Every three months, you’ll get a Medicare Summary Notice in the mail. It will tell you the amount that Medicare paid for services you received. You can also view your Medicare Summary Notice on the Medicare.gov website.

For people in Original Medicare, you can file an appeal by following the instructions on your Medicare Summary Notice. You have 120 days from the time you receive your notice to file an appeal.

When you receive care from a hospital, Skilled Nursing Facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice care, you might be able to file a fast appeal if you think your services are ending too soon.

Your provider will give you instructions on how to file a fast appeal, but you can also get information on Original Medicare Appeals from the California Health Advocates' website.

Prescription Drug Coverage

With Original Medicare, you have to decide whether or not you want to get Medicare’s Prescription Drug Coverage, which is known as Part D.

Medicare Part D is offered through private companies that have agreed to follow Medicare's rules. You pay premiums, coinsurance, and copayments, although help is available for those who can’t afford these costs. DB101's section on Part D goes into more detail.

Medigap

As you learn more about Original Medicare (Medicare Parts A and B), you’ll notice that there are certain things that it will not pay for.

Examples of gaps in Original Medicare coverage:
• Parts A and B may not pay for the first three pints of blood when you need a transfusion
• For most Part B services, you pay for 20% of the cost while Medicare pays for 80%

Medigap policies (also called Medicare Supplemental Insurance Policies) are private health insurance policies that can help pay for these gaps in Original Medicare coverage. These policies are offered by licensed insurance companies. The California Department of Insurance is in charge of making sure these companies follow the rules.

To buy a Medigap policy, you must have both Medicare Parts A and B. In general, Medigap policies do not provide any Medicare Part D Prescription Drug Coverage. The California Health Advocates' website has an excellent description of Medigap in California.

Medicare and Other Health Coverage

When you get Medicare, you may already have health coverage from another source. In some cases, this other health coverage can help pay for costs that Medicare doesn’t pay for.

One source of other coverage might be from an employer. If you’re still working, this could be coverage from a current employer. If you’ve stopped working, you may have coverage from an employer through COBRA or Cal-COBRA, which may allow you to keep health coverage from a former employer for 36 months or more after you leave a job. You may also have coverage through a spouse’s employer.

Besides employer sponsored coverage, there are a number of other types of coverage that interact with Medicare. These include retiree benefits, Veterans (VA) benefits, military (TriCare) benefits, and individual health insurance. The rules for how Medicare interacts with other health coverage can be complicated. California Health Advocates has more information on these rules.

Another source of coverage is Medi-Cal, which helps people with low income pay for medical expenses. You can be on both Medi-Cal and Medicare at the same time. When you see a provider for health care, make sure that they accept both Medi-Cal and Medicare.

Medi-Cal interacts with Medicare in a number of ways:

  • Generally, Medicare gets the bill for the service first and pays for whatever it covers. Medi-Cal then pays for the remainder.
  • For people on Medicare and Medi-Cal, there are special rules about choosing, signing up for, and getting help paying for Part D Prescription Drug Coverage. See Part D for more information.
  • Medi-Cal may help pay for some of your Medicare costs, like Part B premiums. See Part B for more details.
  • DB101's section on Medi-Cal has more information on the Medi-Cal program.
Combined managed care plans for some people with both Medicare and Medi-Cal

Starting in 2014, some people who qualify for Medicare and Medi-Cal coverage at the same time get their health coverage through combined managed care plans called “Cal MediConnect” plans. That means they have just one card for their Medicare and Medi-Cal and any billing automatically takes into account the benefits both programs provide. This makes things simpler for people with these Cal MediConnect combined coverage plans.

Not everyone on Medicare and Medi-Cal has this option. It's only for people who live in seven California counties: Alameda, Los Angeles, Riverside, San Bernadino, San Diego, San Mateo, and Santa Clara. Most of these counties have more than one Cal MediConnect combined managed care option – so you may just hear it referred to by the names of the insurance companies or non-profits running the plans in your county.

Not everybody gets to choose a Cal MediConnect plan at the same time. If and when you have the option to choose a Cal MediConnect plan, you should get letters from your county with more information. It is important to read these letters, since the plan you choose could impact which doctors you can visit.

Read more about combined managed care for Medicare and Medi-Cal or call the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222.

How Medicare Benefits Might Change Over Time

Transition from SSDI to Retirement Benefits

If you are under 65 and getting benefits because of a disability, there are a number of different ways that your benefits could change over time.

For example, let’s say you are 50 years old and have been getting disability payments for the past 5 years and are currently on Medicare Parts A and B through Original Medicare. One possibility is that you stay disabled and can’t ever return to work. In this scenario, your disability benefits would continue until you reach full retirement age, at which point your SSDI would automatically change to retirement benefits. Your Medicare benefits wouldn’t change.

Returning to Work

Another possibility is that you return to work before you reach what Social Security considers your full retirement age. When you go back to work, you may eventually lose your free Part A coverage. This doesn’t happen until almost 8 years after you go back to work and, once it does, you may be eligible to have the state pay for Part A coverage. See Part A and Returning to Work for more details.

Changing Your Medicare Coverage

Another possibility is that you will want to change your Medicare options. You may, for example, want to switch to Medicare Part C (Medicare Advantage), buy a Medigap policy, or enroll in Parts B or D.

Sources

The following links are provided for those who want detailed information on Medicare. For those looking for more general information, please go to the Medicare Resources Page.

Medicare and You from the Centers for Medicare and Medicaid Services gives an excellent overview of Medicare benefits.

Social Security’s website provides general information for Medicare beneficiaries and has access to more detailed information for providers and advocates.

California Health Advocates is an excellent website that gives detailed information for both consumers and advocates on all aspects of the Medicare program.