Medicaid and Medicare: An Overview
Both SSA disability programs have health insurance programs associated with them. For SSI it is Medicaid; for SSDI it is Medicare which begins two years after the date of eligibility. Establishing eligibility for SSI or SSDI can be key to connecting with Medicaid or Medicare health insurance.
- Medicaid is administered through a federal and state partnership. Each state has a unique Medicaid plan and eligibility rules.
- For questions about Medicaid in your state, visit Medcaid.gov.
Medicaid is available to adults who have low-income in states that have expanded access under the Affordable Care Act (ACA). Medicaid is also available to “categorically eligible” individuals. In most states, eligibility for SSI confers eligibility for Medicaid.
- Medicaid eligibility is automatic upon SSI approval in 32 states. In these states the SSI application is the Medicaid application
- In 7 states (Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon, Utah) they use the same eligibility rules as SSA uses for SSI, but they require a separate application (as long as you file both applications and are SSI eligible you should be Medicaid eligible)
- The other 11 states (Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, Virginia) have established additional rules and require a separate application. In these states, SSA or your SOAR State Lead can direct you to the office where you can apply for Medicaid
State Medicaid programs follow federal guidelines when establishing their services, but each state is able to determine the types of services offered. However, states must cover "mandatory benefits," and may choose to provide other "optional benefits" through the Medicaid program.
|Mandatory Benefits||Optional Benefits|
|Sample of included benefits (not complete):
||Sample of included benefits (not complete):
- Medicare is a federally administered health insurance program for people who are age 65 or older and for those who are eligible for SSDI benefits, after the two-year waiting period.
- Medicare is the same in every state.
- Medicare is managed by the Centers for Medicare and Medicaid Services (CMS). Social Security works with CMS by enrolling people in Medicare.
Recipients of SSDI are eligible for Medicare two years after eligibility for SSDI began.
- Remember that eligibility for SSDI may have started in the past and back payments may have been paid
- Individuals with Lou Gehrig’s (ALS) or end stage renal diseases are immediately eligible for Medicare
Medicare benefits are categorized into four different parts that provide different coverage and have related expenses: including premiums, deductibles, and co-pays.
|Part A||Hospital insurance that helps cover inpatient care||Most people do not pay a premium for Part A|
|Part B||Helps cover medically necessary services like doctor’s visits, outpatient hospital care, and other medical services||Enrollment in Part B requires a monthly premium (To see current amounts, see SSA Annual Updates)|
|Part C||Consists of Medicare Advantage Plans, optional health plan choices (like HMOs or PPOs) through private Medicare-approved agencies||People with Medicare Parts A and B can choose to receive all of their health care services through plans provided by private Medicare-approved agencies. Each plan has different rules, costs, and coverage options and beneficiaries should compare plans to find what best meets their needs.|
|Part D||Prescription drug coverage||Enrollment in Part D is limited to the period when the beneficiary is first eligible for Medicare and the Medicare open enrollment period each year (October 15-December 7). Some Medicare Advantage Plans (Part C) come with prescription drug coverage. If that applies, beneficiaries do not need separate Part D coverage.|
Visit the Medicare.gov for questions and additional information about Medicare.