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Medicaid and Medicare and disability

Posted: July 30, 2021

Last Updated Date: July 30, 2021

What is Medicaid and who is eligible?

Medicaid is a federal and state program that provides health care coverage to qualified individuals. People who are eligible for Medicaid include:

  • Pregnant women with low income
  • Children of low-income families
  • Children in foster care
  • People with disabilities
  • Seniors with low income
  • Parents or caregivers with low income

Medicaid programs are state-run. So states can choose to provide Medicaid to more people, such as individuals with low income who may or may not have children.

More than 10 million people qualify for Medicaid based on having a disability.
MACPAC (Medicaid and CHIP Payment and Access Commission)

What if I have a disability?

People with disabilities or chronic conditions and low incomes are eligible for Medicaid. All states also provide aged, blind and disabled (ABD) Medicaid benefits. ABD Medicaid is for adults 65 and older or anyone who is disabled according to Social Security. But you also need to meet the financial eligibility requirements in your state.

Whether you qualify for Medicaid or Medicare depends on the type of disability benefits you’re getting.

  • If you have Supplemental Security Income (SSI) disability:
    You’ll be eligible for Medicaid coverage. In many states, you’ll get Medicaid automatically. But in other states, you’ll need to sign up for Medicaid.
  • If you’re getting Social Security Disability Income (SSDI):
    You’ll qualify for Medicare.

What conditions qualify as a disability?

No matter whether you have SSI, SSDI, Medicaid, ABD Medicaid or Medicare, the medical requirements are the same. First, you must meet the non-medical disability requirements. These are based mainly on your work history and social security taxes you’ve paid. Then, monthly disability benefits are paid if a medical condition is expected to last at least 1 year or result in death.

Different types of medical conditions that qualify as a disability for adults over age 18 are listed in the chart below. Note that the chart shows a general list. It doesn’t include every condition that may qualify adults for social security disability. For a full list of qualifying conditions visit the Social Security Administration (SSA) website There’s also a separate childhood listing that shows impairments for children with disabilities.

Qualifying Health Disorder

Description

Musculoskeletal system (muscles, bones and joints)

Problems such as muscle weakness, limited range of movement and loss of or slow reflexes

Special senses and speech

Loss of vision that limits seeing fine detail, reading or out of the corners of the eye

Respiration (breathing)

Difficulty with breathing, such as with COPD, chronic bronchitis and emphysema, asthma and cystic fibrosis

Cardiovascular system (heart and blood vessels)

Disorders that prevent the heart or the circulatory system (arteries, veins and blood vessels) from working properly

Digestive system

Digestive problems, including hepatic (liver) dysfunction, inflammatory bowel disease, short bowel syndrome, and malnutrition

Genitourinary (kidney)

Disorders resulting in chronic kidney disease (CKD)

Hematological (blood)

Non-cancerous problems with the development and working of white and red blood cells and blood clotting

Skin

Skin problems, including chronic infections of the skin or mucous membranes, dermatitis and burns

Endocrine (hormonal) imbalance

Medical conditions that cause bodily glands to produce too much of a specific hormone (hyperfunction) or too little (hypofunction)

Congenital disorders (birth defects) that affect multiple body systems

Down syndrome and other birth defects, including Tay-Sachs disease, phenylketonuria (PKU) and fetal alcohol syndrome

Neurological (brain and nervous system)

Conditions that limit physical and mental functioning, such as epilepsy, ALS, coma and early-onset Alzheimer’s disease

Mental disorders

Covers a wide range of mental disorders, including schizophrenia, depressive, bipolar and related disorders, OCD, autism, eating disorders and trauma- and stressor-related disorders

Cancer

All types of cancer except certain cancers associated with human immunodeficiency virus (HIV) infection

Immune system

Disorders that effect the immune system, including rheumatic diseases, connective tissue disorders and human immunodeficiency virus (HIV) infection

What if you’re under age 65 and have a disability?

People under age 65 with disabilities automatically qualify to get Original Medicare (Parts A and B) after they’ve been receiving disability benefits from Social Security for 24 months. If you also qualify for Medicaid or Medicaid disability, your state Medicaid program may help pay for costs and services that Medicare does not cover. For any services that are covered by both Medicare and Medicaid (such as doctor visits, hospital care, home care and skilled nursing facility care), Medicare will pay first. Medicaid may also pay for added costs or services, but only after the Medicare share has been used up.

What is dual-eligible or dual special needs coverage?

More than10 million people qualify for Medicaid based on having a disability.1 There are also more than 12 million people who qualify for both Medicare and Medicaid.2 These people are known as “dual-eligibles” because they’re dually eligible for Medicare and Medicaid. Dual-eligible health plans offer more benefits than Original Medicare. But the thing is, a lot of people who could qualify for a Dual Special Needs Plan don’t know these plans exist.

What is a Dual Special Needs Plan?

Dual Special Needs Plans are for people who could use some extra help. That may be because of income, disabilities, age and/or health conditions. Dual Special Needs Plans are a special type of Medicare Advantage plan. They include everything you get with Original Medicare, plus prescription drug coverage and many other extra benefits on top. And you could get it all with as low as a $0 plan premium. 

How to enroll in a Dual Special Needs Plan

To see if you qualify for a Dual Special Needs Plan, read this article. Or use the search box below to find dual health plans available in your area.

1 MACPAC (Medicaid and CHIP Payment and Access Commission) 
2 CMS Medicare-Medicaid Coordination Office analytics webpage

 

See UnitedHealthcare plans in your area.

Please note that the specific benefits dual health plans include can change depending on where you live. Search by your ZIP code to find the right plan to meet your health care needs. 

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