Medicare

Medicare is federal health insurance primarily for people age 65+, but also available to some younger disabled people. This page explains Medicare in plain language and provides guidance for disabled people navigating it.

About Medicare

Medicare is:

Health insurance: Covers doctor visits, hospital care, prescription drugs, and other medical services
Federal program: Run by Centers for Medicare & Medicaid Services (CMS)
Mandatory payroll tax: Funded by FICA taxes (Social Security and Medicare tax)
Age-based and disability-based: Available at 65+ or earlier if disabled

Medicare is not Medicaid. They’re completely different programs.

Who Qualifies for Medicare

You can get Medicare if you:

Age requirement:

You’re 65 or older, OR
You’re under 65 and:
- You’ve received SSDI (Social Security Disability Insurance) for 24 months, OR
- You have End-Stage Renal Disease (ESRD), OR
- You have ALS (Lou Gehrig’s disease)

Work history:

You or your spouse worked and paid Medicare taxes for at least 10 years (40 quarters)

Citizenship:

U.S. citizen or permanent resident (5+ years)

Medicare Parts: What They Cover

Medicare has different “parts.” You don’t have to take all of them, but understanding what each covers helps you choose.

Part A: Hospital Insurance

Covers:

Hospital inpatient care
Skilled nursing facility (short-term, after hospitalization)
Hospice care
Home health care (in some situations)

Cost:

No monthly premium (most people)
Deductible: $1,736 per benefit period (2026)
Copayments/coinsurance for longer stays

When you need it: If you’re hospitalized, admitted to nursing home, or need hospice

Part B: Medical Insurance

Covers:

Doctor visits
Outpatient care
Diagnostic tests and imaging
Mental health services
Physical and occupational therapy
Durable medical equipment
Ambulance
Many preventive services

Cost:

Monthly premium: $202.90 standard; higher for higher incomes via IRMAA (2026)
Annual deductible: $283 (2026)
Copay or coinsurance (20% of approved amount after deductible)

When you need it: Regular doctor appointments, preventive care, testing

Part D: Prescription Drug Coverage

Covers:

Prescription medications
Coverage varies by plan
Some drugs cost more than others (tiers)

Cost:

Monthly premium: varies by plan and region
Annual deductible: Up to $615 (2026)
Copay for each prescription: varies by plan and drug tier
Out-of-pocket cap: As of 2025 the “donut hole” is gone — once your out-of-pocket drug costs reach $2,100 (2026), you pay $0 for covered drugs for the rest of the year

When you need it: If you take prescription medications

Part C: Medicare Advantage

What it is: Private insurance alternative to Original Medicare

Covers Part A and B services
Usually includes Part D (drugs)
Often includes dental, vision, hearing (varies)
HMO or PPO model (network doctors)

Cost:

Lower or $0 monthly premium
BUT: Higher out-of-pocket costs when you use services
Often network-based (must use certain doctors)

Pros:

Might have drug coverage included
Sometimes dental/vision included
Lower premiums

Cons:

Limited provider networks
Copays/coinsurance and referral rules vary by plan — many plans require referrals for specialists and charge per-service costs
Coverage and out-of-pocket costs vary a lot by plan
Can be hard to switch plans

Enrollment

Initial Enrollment Period:

7 months around your 65th birthday (3 before, month of, 3 after)
Missing this deadline = permanent penalty (1% extra per month delayed)

Automatic enrollment:

If you get SSDI, you’re automatically enrolled in Parts A & B 24 months after SSDI starts

Late enrollment penalties:

Missing enrollment deadlines = permanent cost increases
Only exceptions: qualifying life events, creditable coverage from employer

Changing plans:

Annual Enrollment Period: October 15 - December 7
Can switch between Original Medicare and Medicare Advantage
Can change Part D plans

Paying for Medicare

Medicare costs vary based on:

Your income:

Higher income = higher premiums
Income thresholds determined by CMS

Your coverage choice:

Original Medicare + Supplement insurance: Higher monthly cost
Medicare Advantage: Often lower monthly premium

Prescription drugs:

Part D premium varies
(The old Part D “donut hole” no longer applies — Part D now has a yearly out-of-pocket cap; see the Part D section above)

Low-income help:

Qualified Medicare Beneficiary (QMB): Covers Part B premium
Specified Low-Income Medicare Beneficiary (SLMB): Covers Part B premium
Medicaid (in some states) covers cost-sharing
Extra Help program for Part D: Reduced drug costs

Medicare Advantage vs. Original Medicare

Feature	Original Medicare	Medicare Advantage
Provider choice	Go to any doctor	Network doctors only
Referrals	Don’t need referrals	Often need referrals
Out-of-pocket maximum	None (can be unlimited)	Usually has maximum
Prescription drugs	Part D separate	Often included
Extra benefits	No	Sometimes (dental, vision)
Switching	Can switch any time	Limited to enrollment periods
Cost predictability	Varies by service	More predictable

Supplemental Insurance (Medigap)

Supplemental insurance helps pay costs Medicare doesn’t cover.

Who should get it:

If on Original Medicare
Have predictable healthcare costs
Want coverage predictability

Plans A-N: Different levels of coverage

Cost: varies widely by plan letter, age, and location

Where to buy: Private insurance companies (Medicare.gov has tool)

Medicaid and Medicare

Medicare + Medicaid (Dual Eligible):

If you qualify for both, you get benefits from both
Medicare is primary
Medicaid covers cost-sharing and fills gaps
States run Medicaid, so coverage varies

Interactions:

Eligibility for each determined separately
Income and resource limits different
Both can cover same service (usually Medicare pays first)

Working While on Medicare

If you work before 65 and become disabled:

Before 24 months of SSDI:

Work incentives let you earn without losing SSDI
Trial Work Period: 9 months of unlimited earnings
Medicaid continuation possible
Extended eligibility period

After 24 months (when Medicare starts):

Medicare continues even if you work and earn above SSDI limit
Healthcare covered even if SSDI stops due to work

Disability-Specific Medicare Considerations

Disabled people on Medicare often:

Need more healthcare than general population
Have complicated medical needs
May need assistive technology and equipment
May need mental health and behavioral health services
May need home health care

Things to understand:

Medicare has specific rules for medical equipment
Prior authorization often required
Coverage can be complex
Appeals possible if coverage denied

Appealing Medicare Denial

If Medicare denies a service or medication:

Process:

Reconsideration: Request within 180 days
Hearing: Administrative Law Judge hears case
Appeals Council: Medicare’s appeals council reviews
Federal Court: Can file lawsuit in federal court

Getting help:

Medicare.gov has appeal forms
Patient advocates available
Legal aid organizations
Medicare beneficiary counseling (free, in every state)

What helps:

Medical documentation
Doctor’s statement about medical necessity
Evidence policy decision was wrong
Patient advocate assistance

Finding Doctors and Services

Medicare.gov search tool: Find doctors accepting Medicare

Questions to ask:

Do you accept Medicare?
What’s your copay/coinsurance?
Do you take Medicare Advantage plans (if you’re on MA)?
How do I get a referral if needed?

Mental health: Mental health professionals may be limited

Find providers at Medicare.gov
May have copays or coinsurance
Different rates for individual vs. group therapy

Medication Coverage

Part D (prescription drugs):

Compare plans at Medicare.gov
Different plans cover different drugs
Copays vary by “tier”
Check if your medications covered before enrolling

Out-of-pocket maximum (replaced the old “donut hole”):

As of 2025, Part D has a hard yearly cap on out-of-pocket drug costs
In 2026, once you have paid $2,100 out of pocket, you pay $0 for covered drugs for the rest of the year
The old coverage-gap (“donut hole”) phase no longer exists
An optional Medicare Prescription Payment Plan lets you spread costs across the year

Low-income help:

Extra Help program: Reduced Part D costs
Medicaid (in dual-eligible states)
Manufacturer patient assistance programs

Assistive Technology and Medical Equipment

Medicare covers assistive technology and medical equipment when:

Doctor orders it as medically necessary
Specific requirements met (varies by item)
Usually Part B (20% coinsurance after deductible)

Examples:

Wheelchairs and scooters
CPAP machines
Oxygen
Walkers and canes
Hospital beds and patient lifts
Speech-generating devices (sometimes)

Note: Medicare generally does not cover most bathroom safety equipment (grab bars, shower chairs, raised toilet seats) — it treats them as not “primarily medical.” Medicaid or other programs may help.

Requirements:

Prescription from doctor
Often prior authorization needed
Specific supplier requirements
May have rental vs. purchase rules

Advocacy and Support

Getting help:

State Health Insurance Assistance Program (SHIP): Free counseling (1-800-MEDICARE)
Medicare.gov: Comprehensive information
Disability Rights organizations
Patient advocates

Dispute coverage:

Medicare beneficiary ombudsman
Legal aid organizations
Disability advocacy groups
Patient advocates

Common Medicare Myths

Myth: “Medicare covers everything” Truth: Medicare has gaps; coinsurance, deductibles, and uncovered services mean costs

Myth: “You can only get Medicare at 65” Truth: Disabled people can get it earlier if they meet requirements

Myth: “I lose Medicare if I work” Truth: Medicare continues; working may stop SSDI but Medicare continues

Myth: “Original Medicare is always better” Truth: Medicare Advantage works better for some people; depends on needs and budget

Myth: “I can change Medicare plans anytime” Truth: Generally limited to annual enrollment periods; exceptions for life events

Next Steps

Check eligibility: Call 1-800-MEDICARE or visit Medicare.gov
Understand your options: Compare Original Medicare vs. Medicare Advantage
Enroll during correct period: Don’t miss deadlines (permanent penalties)
Choose prescription drug plan: Part D required if taking medications
Get help: Call for free counseling if confused

Contributing Medicare Resources

Have you navigated Medicare as a disabled person? Know about resources that should be included? Have coverage tips?

We welcome contributions from disabled Medicare beneficiaries, healthcare advocates, and Medicare specialists.

Contribute →

Need immediate help? Call Medicare: 1-800-MEDICARE (1-800-633-4227) | TTY: 1-877-486-2048

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