Social Security Disability Insurance and the Medicare Waiting Period

Winning a Social Security Disability Insurance claim not only entitles an individual to cash benefits, but it also entitles a beneficiary to Medicare insurance.  Due to the rising costs of medical treatment and insurance premiums, Medicare entitlement is often the primary reason that claimants apply for Social Security Disability. When planning to apply for Social Security Disability Insurance, however, one must keep in mind that Medicare has a 24 month waiting period for entitlement after an individual becomes entitled to cash benefits through the Social Security Administration (“SSA”). What does this mean exactly you may ask? Let me tell you.

Let us take an individual whose onset of disability is July 1, 2015. The Social Security Administration has a standing rule that every individual must be disabled for a full five months before he or she becomes entitled to a cash benefit. Thus, in this example, the individual’s entitlement date for cash benefits is December 1, 2015. Add two years to this date-of-entitlement for cash benefits and you have the Medicare entitlement date of December 1, 2017.

As you can imagine, this two year waiting period can be devastating to individuals who desperately need medical insurance to treat chronic conditions. The Medicare waiting period developed due to the impression that COBRA insurance from the former employer would fill in the gap of medical insurance while a claimant waited for Medicare entitlement.

Federal COBRA regulations allow a former employee to stay on his or her employer’s insurance plan for a maximum of 18 months. While COBRA does have an extension program that allows COBRA insurance to be extended up to a maximum of 29 months, if an individual is found disabled by the Social Security Administration, it fails to take into account two major problems. First, in order to be entitled to a COBRA extension, a claimant must be found disabled by the Social Security Administration within the initial 18 months that an individual is entitled to COBRA insurance. Most individuals who apply for Social Security Disability are required to attend a hearing in front of an Administrative Law Judge (“ALJ”). On average, it takes 2 to 2 ½ years to have a hearing with an ALJ. Thus, many individuals do not get their favorable determination from Social Security Disability within the 18 month window that COBRA requires. Second, the COBRA premiums are often so high that they are cost-prohibitive for a former employee to afford. Many former employers do not elect to take the COBRA insurance due to the high monthly costs. Thus, COBRA insurance and COBRA extensions are not always realistic options for medical insurance during SSA’s Medicare waiting period.

There are two exceptions to the Medicare waiting period with SSA. The usual 24 month waiting period for Medicare has been eliminated for SSDI recipients diagnosed with Amyotrophic Lateral Sclerosis (“ALS”), sometimes referred to as Lou Gehrig's disease, and individuals diagnosed with end-stage renal disease or kidney failure. These two exceptions are due to the poor prognosis of these diseases and the result of extensive lobbying efforts by support groups and advocates who work with individuals from these populations. In spite of the countless other life-threatening diseases out there, no other groups have been successful in eliminating the waiting period for Medicare.

Please keep in mind that these Medicare waiting periods only apply to Social Security Disability recipients. Individuals found eligible for SSA’s Supplemental Security Income program and MediCal/Medicaid insurance, are not subjected to any waiting periods.

Got a question about SSDI or SSI that you need us to answer? Please check out our website at www.westcoastdisability.com . We try to provide you with helpful information on our website that will allow you to successfully navigate the Social Security Disability process. Also, feel free to email me your questions at megan@westcoastdisability.com or call me at (800) 459-3017 x 103.