When you experience a long-term disability, ongoing healthcare is essential to managing your condition while you apply for disability benefits. Due to the long waiting period for healthcare coverage when you qualify for Social Security Disability Insurance (SSDI), questions about how to maintain health insurance coverage often arise. We hope to clarify the types of health insurance available through SSDI, how it integrates with other health plans, and what happens to employer-provided insurance if you go on disability.
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Steps for SSD Claimants Without Health Insurance: Key Takeaways
Understanding the key benefits of health insurance options for Social Security Disability Insurance (SSDI) recipients will help you navigate your healthcare needs. Here are the main points to consider:
- SSDI recipients generally qualify for Medicare after a 24-month waiting period.
- Medicaid is available for SSI recipients and some low-income SSDI recipients.
- Employer-provided health insurance may be retained or canceled based on employment status and FMLA protections.
- Employer-sponsored health insurance can be compared with ACA Marketplace plans and COBRA, often revealing potential cost savings with Medicare coverage.
- Special Needs Plans (SNPs) offer additional Medicare benefits for specific conditions.
What Insurance Do You Get With Social Security Disability Benefits?
Getting Social Security Disability benefits gives you access to health insurance options to help you manage your disability care. The kind of insurance, as well as how quickly you receive it, varies if you get SSI or SSDI.
SSI and Medicaid
Supplemental Security Income (SSI) recipients usually get Medicaid. Medicaid provides full health coverage including doctor visits, hospital stays, long-term care, and home health services. Eligibility and benefits vary by state but are designed so disabled, low-income individuals can get the medical care they need. In many states, SSI recipients are automatically enrolled in Medicaid, which they’ll maintain for the full period they’re receiving SSI benefits. Medicaid can provide coverage for an extended period for those who qualify.
SSDI and Medicare
Everyone eligible for Social Security Disability Insurance (SSDI) benefits is eligible for Medicare after 24 months. Medicare has multiple parts: Part A covers hospital care, Part B covers outpatient and preventive services, Part C (Medicare Advantage) offers extra benefits through private insurance and Part D covers prescription drugs. So SSDI recipients get full health coverage, but there’s a waiting period before you qualify.
Can You Get Health Insurance Coverage on SSDI?
Qualifying for Social Security Disability Insurance (SSDI) often brings up concerns about health insurance coverage. SSDI recipients typically become eligible for Medicare after a waiting period. It’s important to understand how Medicare, Medicaid, and other health insurance options work while on SSDI.
Medicare Eligibility and Coverage Parts (A, B, C, D)
Medicare is the health insurance for SSDI recipients but there is a 24-month waiting period before benefits start. Medicare Part A covers hospital stays, skilled nursing facilities, hospice care, and some home health care. Medicare Part B covers outpatient care, doctor services, preventive services, and some home health visits. Medicare Part C (Medicare Advantage) is offered by private insurance and may include extra benefits like vision, dental and hearing. Medicare Part D covers prescription drugs and helps you manage your medication costs.
Medicaid Eligibility and Coverage
Medicaid is available to SSI recipients and some low-income SSDI recipients. Eligibility and coverage vary by state. Medicaid covers a wide range of services including doctor visits, hospital expenses, long-term care, and some home health care services. In many states, SSI recipients are automatically enrolled in Medicaid so they have access to healthcare.
Employer-Provided Health Insurance and SSDI
Employer-provided health insurance can be kept while on SSDI depending on the employer’s policy and the length of disability leave. The Family and Medical Leave Act (FMLA) protects your job and health benefits for up to 12 weeks. After that, the employer can cancel health insurance if you can’t return to work but you can choose to pay the premiums yourself to keep the coverage. It is crucial to maintain group health plan coverage during disability leave to ensure continuous access to necessary medical services and avoid potential gaps in coverage.
ACA Marketplace Plans During SSDI Waiting Period
The ACA Marketplace offers health insurance plans for those waiting for SSDI approval starting at $10/mo, as health insurance premiums for ACA Marketplace plans are calculated based on your income. These plans can be more affordable with subsidies if your income is reduced due to disability, which makes it a great stopgap while you’re waiting for SSDI healthcare benefits. Once Medicare kicks in you may transition from an ACA plan to Medicare.
COBRA’s Role in Maintaining Coverage
COBRA allows you to keep your employer-provided health insurance for a limited time after you lose your job or reduce your work hours. COBRA can be expensive but it’s a great temporary solution to preserve your health insurance until other insurance options like Medicare become available. Utilizing COBRA can help you avoid the significant financial and medical risks associated with losing health insurance.
Health Insurance Coverage Options for SSDI Recipients During the Waiting Period
When you receive SSDI benefits, there’s a 24-month waiting period before you can receive healthcare benefits from the program. However, your need to access healthcare doesn’t change during this time, so how can you receive the health insurance coverage you need to manage your condition? Fortunately, there are a number of options available for you, including ACA benefits and COBRA continuation coverage.
Option 1: Apply for Medicaid or a Reduced Cost ACA Marketplace Health Insurance Plan
To do this, you have two options. One: create an account at Healthcare.gov and complete an application. You’ll find out if you qualify for premium tax credits and lower costs on a private health plan based on the household size and income information you’ll enter during this process.
Keep in mind as you do so that it will take an unknown period of time to get a decision about your disability status from the Social Security Administration. Also, you don’t yet know what their decision will be. So, when you are estimating your income on the Marketplace application, do not include SSDI payments you think you may get.
You’ll find out if you qualify for Medicaid coverage as you fill out the application.
IMPORTANT: When you fill out your Marketplace application, answer “yes” when asked if you have a disability. This will result in your application being automatically forwarded to your state Medicaid agency. If you qualify, they’ll help you enroll.
The second option is to apply for Medicaid coverage directly through your state agency. Select your state from the menu on this Medicaid page for contact information.
Option 2: Wait for Security Disability Insurance (SSDI) Approval
Once you submit an application for disability benefits, several things need to happen. These all take time:
- The SSA reviews your application to make sure you meet some basic requirements for disability benefits.
- They check whether you worked enough years to qualify and evaluate any current work activities you are able to do.
- The SSA processes your application and forwards your case to the Disability Determination Services office in your state.
- Your state’s DDS agency makes the disability determination decision.
Once your application for disability payments via the Social Security Administration is approved, you will have to wait 24 months before Medicare coverage starts. Because of this delay, it is wise to fill out the ACA application and enroll in a private plan as you wait.
If you get a negative disability decision — meaning your claim is denied — you can still fill out a Marketplace application to apply for coverage. You may learn at this time you qualify for free Medicaid. As an individual, your income cannot be higher than $13,590/year to qualify for free coverage. For two people, the income limit is $18,310; for a family of three, the number is $23,030/year. Even if find out you don’t qualify for Medicaid because your annual household income is above the threshold, you may qualify for an ACA health plan at a reduced monthly cost.
Related: SSD Benefits Application Timeline: What to Expect
Option 3: Affordable Care Act Healthcare Coverage
The Affordable Care Act plans may be a good option for you and your family regardless of the status of your application for disability benefits. These plans can cost as little as $10/month because the Biden administration used the American Rescue Plan to extend subsidies for the 12 states that did not expand Medicaid. Those states that did expand the program made Medicaid accessible for people under 138% of the Federal Poverty Level (FPL).
ACA plans are a great way to get health insurance. In some cases, these plans are even available to you and your family for free. Call this number for a free health insurance evaluation to see if you qualify: 1-888-292-6667.
If you prefer to look online to see income thresholds yourself, here are the poverty guidelines for 2024.
Medicare and Medicaid Coverage Details
Knowing the details of Medicare and Medicaid coverage helps SSDI recipients manage their healthcare. Both programs offer comprehensive benefits but eligibility and coverage details vary.
Breakdown of Medicare Parts A, B, C, D
| Medicare Part | Coverage Details |
|---|---|
| Part A | Hospital stays, skilled nursing facilities, hospice care, some home health care |
| Part B | Outpatient care, doctor services, preventive services, some home health visits |
| Part C | Medicare Advantage, includes additional benefits like vision, dental, hearing, offered by private insurers |
| Part D | Prescription drug coverage, helps manage medication costs |
Medicaid Coverage Differences Across States and for SSI vs. SSDI Recipients
Medicaid coverage varies by state and offers different levels of benefits. SSI recipients are automatically eligible for Medicaid and cover services such as doctor visits, hospital expenses, long-term care, and some home health care services. Low-income SSDI recipients may also be eligible but state-specific rules apply.
Special Needs Plans and Dual Eligibility Benefits
Special Needs Plans (SNPs) are for individuals with specific diseases or dual eligibility (qualifying for both Medicare and Medicaid). These plans offer specialized health services and care coordination for those with complex health needs.
Employer-Provided Health Insurance and FMLA Protections
Employer-provided health insurance is important for many especially when transitioning to SSDI. Knowing how FMLA works can help you keep your coverage during disability leave.
FMLA Benefits and Limitations
The Family and Medical Leave Act (FMLA) provides up to 12 weeks of job-protected leave with continued health insurance coverage. This protection is available to employees who have worked for the employer for at least 12 months.
How Long-Term Disability Affects Employer-Provided Health Insurance
After the FMLA period, your employer may have the right to drop your health insurance if you can’t return to work. It’s important to look into other health insurance options during this time to keep coverage. Additionally, receiving long-term disability benefits can also impact your health insurance coverage, so it’s crucial to understand how these benefits interact with your existing health plan.
Alternatives if Employer-Provided Insurance is Lost (COBRA, Spouse’s Plan)
If your employer drops your health insurance alternatives like COBRA can help. COBRA allows you to keep your employer’s plan temporarily but it can be expensive. Another option is to enroll in a spouse’s health insurance plan if available, or a parent’s if you’re under 26 and qualify as a dependent.
Additionally, you might consider group health insurance plans as an alternative.
Ready to see if you may qualify? Click here to get a FREE, no-obligation consultation before starting your claim.
Health Care Coverage for SSI and SSDI: Frequently Asked Questions (FAQ)
Can you get Medicare immediately after SSDI approval?
No, there is a 24-month waiting period after SSDI approval before you can get Medicare. However, during this waiting period, you may be eligible for other health insurance options like Medicaid or ACA Marketplace plans.
What happens to my health insurance if I return to work?
If you go back to work your SSDI and Medicare eligibility may change based on your earnings and ability to do SGA. However, there are work incentives and programs that can help you keep your Medicare coverage for a period even if you go back to work.
How does COBRA work with SSDI?
COBRA allows you to keep your employer-provided health insurance for a limited time after you lose your job or reduce your work hours. COBRA can be expensive but it’s a temporary solution until other insurance options like Medicare become available. If you are eligible for SSDI you may be entitled to an extended COBRA coverage period of up to 29 months.
What are Special Needs Plans (SNPs)?
Special Needs Plans (SNPs) are Medicare Advantage plans for individuals with specific diseases or dual eligibility (qualifying for both Medicare and Medicaid). These plans offer specialized benefits and care coordination for their members.
How do I apply for Medicaid if I have a disability?
To apply for Medicaid, visit your state’s Medicaid office or website, or create an account on Healthcare.gov. Answer “yes” to disability on the application to ensure your application is forwarded to the state Medicaid agency. Eligibility and coverage details vary by state, so it’s important to check specific state requirements.
Can my employer cancel my health insurance while on long-term disability?
Yes, after the FMLA protections expire (usually 12 weeks) your employer can drop your health insurance if you can’t return to work. In that case, you may need to look into COBRA, ACA Marketplace plans, or a spouse’s health insurance plan.
You May Qualify for Legal Assistance
Applying for disability benefits and trying to find health insurance coverage at the same time can feel overwhelming. If you need help, talk to an experienced Social Security attorney for free over the phone. Having a disability lawyer file your paperwork makes the process much easier.
Disability lawyers in every state work on contingency, so you’ll pay nothing for claim help now. Click here to sign up for a free, no-obligation phone call with a local attorney near you.
Want free professional help figuring out which ACA plan can help you bridge the Medicare gap? Call 1-888-292-6667 today and our agents will help you find an affordable plan that fits your needs!
Ready to see if you may qualify? Click here to get a FREE, no-obligation consultation before starting your claim.