Medicare for People Under 65: Who Qualifies and How to Enroll

Most people associate Medicare with turning 65, but millions of Americans qualify for Medicare well before that age. If you have a qualifying disability, ALS, or kidney failure, Medicare may be available to you regardless of how old you are.

This guide explains the three pathways to Medicare for people under 65, how enrollment works for each, what coverage you receive, and the unique challenges younger beneficiaries may face with supplemental coverage.

Three Ways to Qualify for Medicare Under 65

There are three main pathways to Medicare for people under age 65. Each has different eligibility rules and timelines.

• Social Security Disability Insurance (SSDI): After receiving SSDI benefits for 24 months, you are automatically enrolled in Medicare.
• ALS (Lou Gehrig's disease): If you qualify for SSDI due to ALS, Medicare begins immediately with no waiting period.
• End-Stage Renal Disease (ESRD): Permanent kidney failure requiring dialysis or a transplant qualifies you for Medicare at any age.

Each pathway has specific rules about when coverage starts, how you enroll, and what additional options are available to you. The following sections cover each one in detail.

SSDI and the 24-Month Waiting Period

The most common way people under 65 qualify for Medicare is through Social Security Disability Insurance (SSDI). SSDI is a federal program that provides income to people who cannot work due to a severe, long-term disability. To qualify for SSDI, you must have a medical condition that meets Social Security's definition of disability, and you must have enough work credits from paying Social Security taxes.

Once approved for SSDI, you must wait 24 months before Medicare coverage begins. The 24-month count starts from the first month you are entitled to SSDI benefits. This is not necessarily the month you first receive a payment, since SSDI has its own 5-month waiting period from the date of disability onset.

Here is a timeline showing how the waiting periods add up:

• Month 0: Your disability begins (the onset date determined by Social Security).
• Month 6: Your SSDI entitlement begins (after the 5-month SSDI waiting period). The Medicare 24-month clock starts here.
• Month 30: Medicare coverage begins (24 months after SSDI entitlement, 29 months after disability onset).

The 29-month gap between disability onset and Medicare coverage can be a difficult period. During this time, you may need to rely on other health coverage options. If you have employer coverage from your own or a spouse's job, that can continue. COBRA allows you to keep employer coverage for up to 18 months. Marketplace plans are available, and you may qualify for premium subsidies based on your reduced income. If your income is very low, you may qualify for Medicaid.

After the 24-month waiting period, Social Security automatically enrolls you in Medicare Parts A and B. Your Medicare card arrives about three months before your coverage start date. You do not need to fill out a separate application.

ALS: No Waiting Period Required

Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig's disease, is the one condition that bypasses the standard 24-month Medicare waiting period entirely. If you are diagnosed with ALS and approved for SSDI, your Medicare coverage starts the same month as your SSDI entitlement.

Congress created this exception because ALS is a rapidly progressive and fatal neurological disease. The standard two-year waiting period would leave patients without Medicare coverage during the time they need it most. With ALS, the 5-month SSDI waiting period may still apply, but the additional 24-month Medicare wait is completely waived.

If you have ALS, enrollment in Medicare Parts A and B is automatic once your SSDI is approved. You will receive your Medicare card shortly after your SSDI approval. Make sure to also consider enrolling in a Part D prescription drug plan, as ALS treatment may involve multiple medications.

People with ALS who are already on Medicare should be aware that both Original Medicare and Medicare Advantage plans cover ALS-related care. This includes doctor visits, hospital stays, home health care, durable medical equipment (such as wheelchairs and respiratory devices), and skilled nursing care.

ESRD: Medicare for Kidney Failure

End-Stage Renal Disease (ESRD) is permanent kidney failure that requires regular dialysis or a kidney transplant to sustain life. If you have ESRD, you may qualify for Medicare at any age, even if you are not old enough for SSDI or do not meet other disability criteria.

To qualify for ESRD-based Medicare, you must meet one of these requirements:

• You have enough Social Security work credits (the amount varies by age)
• You are already receiving Social Security or Railroad Retirement benefits
• You are the spouse or dependent child of someone who meets one of the above criteria

ESRD-based Medicare coverage does not start immediately. The timing depends on your treatment:

• In-center dialysis: Medicare generally begins the fourth month after you start regular dialysis treatments.
• Home dialysis training: If you participate in a home dialysis training program, coverage can begin as early as the first month of training.
• Kidney transplant: Coverage may begin the month you are admitted to the hospital for the transplant, or up to two months before if you need pre-transplant care.

Unlike SSDI-based Medicare, ESRD enrollment is not automatic. You must apply for ESRD-based Medicare through Social Security. Your doctor or dialysis center can help you complete the application, which includes form CMS-2728.

Medicare as Secondary Payer for ESRD

If you have ESRD and also have employer group health coverage, there is a special coordination-of-benefits rule. During the first 30 months of ESRD-based Medicare eligibility, your employer plan is the primary payer and Medicare is the secondary payer. This is called the ESRD coordination period.

During the 30-month coordination period, your employer plan pays first, and Medicare pays second to cover costs your employer plan does not cover. After the 30-month period ends, Medicare becomes the primary payer, and your employer plan becomes secondary.

This coordination period applies regardless of your employer's size. Even employers with fewer than 20 employees follow the 30-month ESRD secondary payer rule. This is different from the standard Medicare coordination rules for people 65 and older, where employer size determines which plan is primary.

It is important to enroll in both Medicare and your employer plan during the coordination period. Having both plans working together can significantly reduce your out-of-pocket costs for dialysis, transplant care, and related treatments.

How to Enroll in Medicare Under 65

The enrollment process depends on which pathway qualifies you for Medicare.

SSDI-based enrollment: Enrollment is automatic. After 24 months of SSDI entitlement, Social Security enrolls you in Medicare Parts A and B. You will receive your Medicare card about three months before coverage begins. No application is needed. If you do not want Part B, you must actively decline it.

ALS-based enrollment: Also automatic. Once your SSDI is approved with an ALS diagnosis, Medicare begins the same month. Your card will arrive shortly after your approval. No separate Medicare application is needed.

ESRD-based enrollment: You must apply. Your doctor or kidney dialysis center will help you complete form CMS-2728 (the ESRD Medical Evidence Report). You then apply for Medicare through Social Security. You can apply online at SSA.gov, by phone at 1-800-772-1213, or in person at your local Social Security office.

Regardless of how you qualify, once you are enrolled in Medicare Parts A and B, you have the same coverage options as any other Medicare beneficiary. You can add a Part D prescription drug plan, switch to a Medicare Advantage plan, or stay with Original Medicare.

What Medicare Covers for People Under 65

Medicare provides the same coverage to beneficiaries under 65 as it does to those 65 and older. There is no reduced benefit package for younger enrollees. Here is what each part covers.

• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care (up to 100 days per benefit period), hospice care, and some home health services.
• Part B (Medical Insurance): Covers doctor visits, outpatient procedures, preventive services, lab tests, durable medical equipment, mental health services, and ambulance services.
• Part D (Prescription Drug Coverage): Available through standalone drug plans if you have Original Medicare, or included in many Medicare Advantage plans. Covers a wide range of prescription medications.

For people with ESRD, Medicare covers dialysis services, kidney transplant surgery, immunosuppressive drugs (anti-rejection medications), and related lab tests. If you have a successful transplant, Medicare coverage continues for a limited time after the transplant. Immunosuppressive drug coverage continues for the life of the transplant under the Medicare Benefit for Immunosuppressive Drugs, which was expanded in 2023.

For people with ALS, Medicare covers specialized equipment such as power wheelchairs, communication devices, breathing machines, and other durable medical equipment essential for daily living. Home health care and hospice services are also covered.

Medigap Eligibility Under 65: State-by-State Variations

One of the biggest challenges for Medicare beneficiaries under 65 is finding supplemental coverage. Medigap (Medicare Supplement) policies help cover out-of-pocket costs like deductibles, coinsurance, and copayments under Original Medicare. For people 65 and older, federal law guarantees a 6-month open enrollment period to buy Medigap with no health questions asked.

However, federal law does not require insurers to sell Medigap to people under 65. This means Medigap access for disabled Medicare beneficiaries varies significantly from state to state.

Here is how the landscape generally breaks down:

• States with full Medigap protections: Some states require insurers to offer Medigap policies to disabled beneficiaries under 65 on the same terms as those 65 and older. These states provide the strongest protections.
• States with partial protections: Some states require insurers to offer at least one Medigap plan to people under 65, but the premiums may be higher than what people over 65 pay.
• States with no protections: In states without Medigap requirements for people under 65, insurers can refuse to sell you a policy, charge much higher premiums, or exclude coverage for pre-existing conditions.

If you are under 65 and cannot get a Medigap policy, a Medicare Advantage plan may be a better option. Medicare Advantage plans have annual out-of-pocket maximums that cap your costs, which provides some of the financial protection that Medigap offers. Check which Medicare Advantage plans are available in your area at Medicare.gov.

To find out your state's rules, contact your State Health Insurance Assistance Program (SHIP). SHIP counselors can tell you exactly which Medigap options are available to you based on your age, location, and disability status.

Transitioning to Age-Based Medicare at 65

If you are already on Medicare due to disability or ESRD when you turn 65, your coverage transitions smoothly to age-based Medicare. You do not lose coverage, and in most cases no action is required on your part. Your Part A and Part B continue without interruption.

The most significant change at 65 is that you receive a new Medigap Open Enrollment Period. This is a 6-month window that starts when you turn 65 and are enrolled in Part B. During this period, insurance companies must sell you any Medigap policy they offer, regardless of your health status. They cannot charge you more because of pre-existing conditions.

This is an important opportunity if you were unable to buy a Medigap policy while under 65 due to state rules or high premiums. At 65, federal protections apply equally to everyone, regardless of how they originally qualified for Medicare.

If you had ESRD-only Medicare (meaning you did not qualify through disability or age), your coverage may change when you turn 65. You will transition to standard age-based Medicare, which means you can now access Medicare Advantage plans if your state previously limited your MA options due to ESRD status. Since 2021, people with ESRD can join Medicare Advantage plans.

Review your coverage options carefully around your 65th birthday. The transition is an ideal time to switch plans, add a Medigap policy, or change your Part D drug plan to better fit your needs.

Coverage During the SSDI Waiting Period

The 24-month Medicare waiting period can leave you without affordable health coverage during a time when you may have significant medical needs. Here are your main options for coverage during the gap.

• Employer coverage: If you have coverage through your own or a spouse's employer, this is generally the best option. Employer plans cannot drop you because of a disability.
• COBRA: If you recently left a job, you may continue your employer coverage through COBRA for up to 18 months. COBRA can be expensive because you pay the full premium plus an administrative fee, but it maintains your existing coverage.
• ACA marketplace plans: You can buy coverage through the Health Insurance Marketplace (Healthcare.gov). Losing your job or losing employer coverage qualifies you for a Special Enrollment Period. You may qualify for premium subsidies based on your reduced income on SSDI.
• Medicaid: If your income is low enough, you may qualify for Medicaid in your state. Medicaid can cover you during the waiting period and continue alongside Medicare once your Medicare coverage starts.

Do not go without health coverage during the waiting period. Medical bills can accumulate quickly, especially if you have a serious disability. Explore all your options and apply for any programs you may qualify for.

Common Questions About Medicare Under 65

People who qualify for Medicare under 65 often have unique questions that do not apply to age-based enrollees. Here are answers to some of the most common concerns.

Does Medicare end if my disability improves? If Social Security determines that you are no longer disabled and your SSDI benefits end, your Medicare coverage can continue for a limited time. Generally, you can keep Medicare for up to 93 months (about 8 years) after a trial work period if you lose SSDI. After that, you would need to find alternative coverage until you turn 65.

Can I work while on Medicare through disability? Yes. Social Security has programs like the Trial Work Period and Extended Period of Eligibility that allow you to test your ability to work without immediately losing SSDI or Medicare. During a trial work period, you can work and earn any amount for up to 9 months within a 60-month period while keeping full SSDI and Medicare benefits.

Does ESRD Medicare end after a kidney transplant? If you qualified for Medicare only through ESRD, your full Medicare coverage generally continues for 36 months after a successful kidney transplant. After that, if you do not qualify through disability or age, you may lose full Medicare coverage. However, the Medicare Benefit for Immunosuppressive Drugs continues to cover anti-rejection medications for the life of the transplant.

Can I have both Medicare and Medicaid? Yes. If you qualify for both programs, you are considered a dual-eligible beneficiary. Medicaid can help pay for Medicare premiums, deductibles, and other cost-sharing. Many states offer Medicare Savings Programs that cover Part B premiums and more for people with limited income and resources.

The Bottom Line

Medicare is not just for people 65 and older. Millions of Americans under 65 receive Medicare coverage through SSDI, ALS, or ESRD. The coverage is identical to what older beneficiaries receive, including Part A, Part B, Part D, and access to Medicare Advantage plans.

The biggest challenge for younger beneficiaries is the waiting period. The 24-month wait after SSDI approval can feel like a long time without Medicare coverage. Planning ahead by securing alternative coverage during the gap is essential. ALS patients are spared this wait, and ESRD patients have their own enrollment timeline tied to dialysis or transplant treatment.

Medigap access is another unique challenge for people under 65. Federal protections do not require insurers to sell Medigap to disabled beneficiaries, so your options depend on your state. If Medigap is unavailable or too expensive, a Medicare Advantage plan with an out-of-pocket maximum can provide financial protection.

When you turn 65, you get a fresh Medigap Open Enrollment Period with full federal protections. This is the ideal time to review your coverage and make any changes. If you have questions about Medicare under 65, contact your State Health Insurance Assistance Program (SHIP) for free, personalized counseling, or call Social Security at 1-800-772-1213.