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How People Under 65 Can Qualify For Medicare Advantage

By Zawn Villines
Medicare is usually for seniors over the age of 65. People with disabilities and those with end-stage renal disease (ESRD) may also qualify.

Medicare Advantage isn't just for seniors. People with certain disabilities, including end-stage renal disease, may be eligible for Medicare Advantage. If you're wondering how people under 65 can qualify for Medicare Advantage, here's how...

Medicare Advantage eligibility with a disability

If you have a disability, you may be eligible for Medicare, including Medicare Advantage. To apply for Medicare with a disability, you must have been unable to work for a year or longer, or have been eligible for Social Security or Railroad Retirement Board benefits for 24 months.

To qualify as a disability, a condition must be severe enough to prevent a person from working, and must be on the Social Security Administration's list of disabling conditions.

Some examples of potentially eligible disabilities include:

  • Chronic respiratory disorders such as cystic fibrosis
  • Chronic liver disease
  • Inflammatory bowel disease
  • Hearing loss

Medicare Advantage eligibility with End-Stage Renal Disease (ESRD)

End-stage renal disease (ESRD) is kidney disease that is severe enough to need dialysis or a kidney transplant. People with ESRD are eligible for original Medicare, but are not typically eligible for Medicare Advantage. There are some exceptions. You may still be eligible for Medicare Advantage if:

  • You enroll in a Special Needs Plan (SNP). SNPs cater to groups of people with shared characteristics, such as a specific disability. There may be SNPs for people with ESRD in your area.
  • You develop ESRD while already enrolled in Medicare Advantage. Depending on the plan's benefits, you may be able to stay in that plan or switch to a similar plan with the same company.
  • You had a successful kidney transplant but are still eligible for Medicare. Medicare coverage generally ends 36 months following a successful kidney transplant.
  • You are already enrolled in a plan with a company that offers a Medicare Advantage plan. For example, if you have employer health benefits you may be able to enroll in Medicare Advantage with the same company.

To become eligible for Medicare Advantage with ESRD, you must meet all Medicare eligibility requirements, in addition to meeting one of more of the above Medicare Advantage eligibility requirements.

People with ESRD become eligible for Medicare when one of the following criteria is met:

  • An eligible person undergoes their fourth month of dialysis care in a dialysis facility.
  • A beneficiary participates in a home dialysis program. In this scenario, they may become eligible during the first month of dialysis.

Coverage ends when you hit either of these benchmarks:

  • It has been 12 months since you stopped dialysis treatment.
  • It has been 36 months since you had a kidney transplant.

Medicare vs. Medicaid

Similar names and program benefits make it easy to confuse Medicare and Medicaid. While Medicare caters primarily to seniors, Medicaid covers low-income people, pregnant women and children, and people with certain disabilities.

You may be eligible for both programs. If so, applying for both can maximize your benefits, because some services covered by one program may not be covered by the other. You can use The Official U.S. Government Site for Medicare online to check your eligibility. To check Medicaid eligibility, visit your state's Medicaid office. You can use The Official U.S. Government Site for Medicare online to find your state's Medicaid office. Many state Medicaid offices also have online eligibility calculators.