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Home > Resources > PAF Publications > PAF Guides & Major Publications > Disability Process Guide > Chapter 3

Once you are approved for SSDI, it is very important that you consider your health insurance options carefully before and after becoming eligible for Medicare. Once you have been receiving SSDI payments for 24 months you will become eligible for Medicare.

What are my health insurance options before I am eligible for Medicare?



Family Medical Leave Act (FMLA)

FMLA entitles eligible employees to take up 12 weeks of unpaid, job-protected leave in a 12-month period for a specified family and medical reasons. The employer may elect to use the calendar year, a fixed 12-month leave or fiscal year, or a 12-month period prior to or after the commencement of leave as the 12-month period. For more information on this Federal Law visit the Department of Labor website at www.dol.gov.

FMLA applies to all:
  • Public agencies, including state, local and federal employers, local education agencies (schools)
  • Private-sector employers who employed 50 or more employees in 20 or more workweeks in the current or proceeding calendar

To be eligible for FMLA benefits, an employee must:
  • work for a covered employer
  • have worked for the employer for a total of 12 months
  • have worked at least 1,250 hours over the previous 12 months
  • work at a location in the United States or in any territory or possession of the United States where at least 50 employees are employed by the employer within 75 miles

A covered employer must grant an eligible employee up to a total of 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons:
  • For the birth and care of the newborn child of the employee
  • For placement where the employee of a son or daughter for adoption or foster care
  • To care for an immediate family member (spouse, child, or parent) with a serious health condition
  • To take medical leave when the employee is unable to work because of a serious health condition

Under some circumstances, employees may take FMLA leave intermittently - which means taking leave in blocks of time, or by reducing their normal weekly or daily work schedule. Also subject to certain conditions, employees or employers may choose to use accrued paid leave (such as sick or vacation leave) to cover some or all of the FMLA leave.

The employer is responsible for designating if an employee's use of paid leave counts as FMLA, based on information from the employee.

A covered employer is required to maintain group health insurance coverage for an employee on FMLA leave whenever such insurance was provided before the leave was taken and on the same terms as if the employee had continued to work. If applicable, arrangements will need to be made for employees to pay their share of health insurance premiums while on leave.

Upon return from FMLA leave, an employee must be restored to the employee's original job, or to an equivalent job with equivalent pay, benefits and other terms and conditions of employment. Employees seeking to use FMLA leave are required to provide 30-day advance notice of the need to take FMLA leave when the need is foreseeable and such notice is practicable.

Employers may also require employees to provide:
  • Medical certification supporting the need for leave due to a serious health complication affecting the employee or an immediate family member
  • Second or third medical opinions (at the employer's expense) and periodic recertification
  • Periodic reports during FMLA leave regarding the employee's status and intent to return to work

When intermittent leave is needed to care for an immediate family member or the employee's own illness, and is for planned medical treatment, the employee must try to schedule treatment so as not to unduly disrupt the employer's operation. Covered employers must post a notice approved by the Secretary of Labor explaining rights.

It is unlawful for any employer to interfere with, restrain or deny the exercise of any right provided by FMLA. It is also unlawful for any employer to discharge or discriminate against any individual for opposing any practice, or because of involvement in any proceeding, relating to FMLA.

(Compliance Guide to the Family and Medical Leave Act, U.S. Department of Labor Employment Standards Administration Wage and Hour Division, WH Publication 1421, December 1996)

The Consolidated Omnibus Reconciliation Act (COBRA)

The Consolidated Omnibus Reconsiliation Act (COBRA) contains provisions giving certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates. Group health coverage is usually more expensive than health coverage for active employees, since ususally the employer pays a part of teh premium for active employees while COBRA participants generally pay the entire premium themselves. It is ordinarily less expensive than individual health coverage.

Who is entitled to benefits under COBRA?
There are three elements to qualifying for COBRA benefits. COBRA establishes specific criteria for plans, qualified beneficiaries and qualifying events.

Plan Coverge
Group health plans for employers with 20 or more employees on more than 50 percent of its typical business days in the previous calendar year are subject to COBRA. Both full and part-time employees are counted to determine whether a plan is subject to COBRA.

Qualified beneficiaries
A qualified beneficiary generally is an individual covered by a group health plan on the day before a qualifying event who is an employee, the employee's spouse or an employee's dependent child. In certain cases, a retired employee, the retired employee's spouse and the retired employee's dependent children may be qualified beneficiaries. In addition, any child born to or placed for adoption with a covered employee during the period of COBRA coverage is considered a quilified beneficiary. Agents, independent contractors and directors who participate in the group health plan may also be qualified.

Qualifying Events
Qualifying events are certain events that would cause an individual to lose health coverage. The following are identified as "qualifying events:"
  • Voluntary or involuntary termination of employment for reasons other than "gross misconduct"
  • Reduction in the number of hours of employment

The qualifying events for spouses are:
  • Voluntary or involuntary termination of employment for reasons other than "gross misconduct"
  • Reduction in the hours of employment worked by the covered employee
  • Divorce or legal separation of the covered employee
  • Death of the covered employee

The qualifying events for dependent children are the same as for the spouse with one addition:
  • Loss of "dependent child" status under the plan rules

(U.S. Department of Labor, Pension and Welfare Benefits Administration, www.dol.gov.pwba, "Frequently Asked Questions")

Special rules for disabled individuals and certain family members may extend the maximum periods of coverage. If a qualified beneficiary is deteremined to be disabled under the Social Security Act within the first 60 days of COBRA coverage, then the qualified beneficiary and all of the qualified beneficiaries in his or her family may be able to extend COBRA coverge for an additional 11 months. However, you may lose all rights to the additional COBRA coverage, if the Notice of the Determination is not provided to the COBRA carrier within 60 days of the date of the determination and before the expiration of the 18 month COBRA period. The qualified beneficiary who is disabled or any qualified beneficiaries in his or her family may notify the plan administrator of the Social Security Determination (US Department of Labor Pension and Welfare Benefits Administration "COBRA" pages 13-14).

Spouse's Policy

If you are married at the time you become disabled and your spouse has an employer group health policy, you maybe eligible to elect coverage under your spouse's policy. You will not be subjected to a pre-existing condition clause, as long as you sign up for your spouse's policy within 63 days of losing your coverage.

Risk Pool Coverage

Some states offer Risk Pool covrage which provides health insurance options for high risk individuals. These are state programs that serve people who have pre-existing health conditions, and often are denied or find it difficult to obtain affordable health coverage in the private market. Contact your State Insurance Commisioner for further information.

Veterans or Former Military Service Personnel

The Veteran's Administration (VA) may be able to help you with your medical expenses. The VA provides hospital care covering a full range of medical services. Outpatient treatment is available for all service connected conditions, or a non-service connected conditions in some cases. Questions regarding health care benefits should be directed to 1-800-733-8387 (HHA-SSA Publication No. 05-10029).

Medicaid

If you become disabled and cannot afford health insurance, you may be eligible for Medicaid. Medicaid is a state administrated health insurance program for those people who cannot afford to pay for some or all of their medical bills.

What are the requirements of getting Medicaid?
To get Medicaid due to disability you you must be disabled and meet state income and resource standards and certain other requirements. In addition you must be a resident of the state, and be a citizen or a qualified immigrant. Legal immigrants can also qualify under certain circumstances depending on their date of entry into the country. Illegal aliens cannot qualify, except for emergency care (www.cms.gov "Medicaid FAQ").

How do I apply for Medicaid?
To find contact information about Medicaid in your state, contact your local Department of Social Services or visit www.cms.hhs.gov/medicaid/statemap.asp and select your state.

What does Medicaid cover?
Medicaid is a state administered program. Each state sets its own guidelines subject to federal rules and guidelines. Certain services must be covered by the states in order to receive federal funds. Other services are optional and are elected by the states (www.cms.gov, "Welcome to Medicaid Site for Consumer Information").

If you are in need of assistance with daily actibities such as bathing, dressing, light housekeeping, transferring, etc., contact social services to request a community based care screening. If approved, you may be able to get aide in your home to assist you with your daily needs. Depending on what is offered in your state, community based care participation might also include incontinence supplies, transportation and medications. Check with your local Medicaid office for state specific information.

How much money can you make and still get Medicaid?
It varies depending on the eligibility group you fall into. Each state sets an income limit for each Medicaid eligibility group and determines what income counts towards that limit. You will need to contact your local Medicaid office or your state to find out what income limits are and how much of your income counts.

Keep in mind that you may lose your Medicaid upon receipt of your first disability check. The amount of your disability may put you over the income guidelines. Check with your caseworker to see if a spend-down program is available. A spend-down will allow you to keep your Medicaid benefits, but you will have to pay a determined dollar amount in medical expenses, determined by your caseworker, for your medical care.

Medicaid versus Medicare
You may think that Medicaid and Medicare are two different names for the same program. Actually, they are two different programs. Medicaid is a state-run program designed primarily to help those with low income and little or no resources. The federal government helps pay for Medicaid, but each state has its own rules about who is eligible and what is covered under Medicaid. Some people qualify for both Medicaid and Medicare (SOCIAL SECURITY- "Medicare", page 4-5, SSA Publication No. 05-10043 March 2001).

What are my health insurance options after I am eligible for Medicare?

What is Medicare?
Medicare is our national health insurance program for people with disabilities, people of any age who have permanent kidney failure, amyotrophic lateral sclerosis (ALS/Lou Gehrig's Disease) and people who are 65 or older. It provides basic protection against the cost of health care, but it does not cover all medical expenses or the cost of most long-term care. Medicare has two parts: Medicare Insurance, Part A which helps pay for care in a hospital and skilled nursing facility, home health care and hospice care; and Medical Insurance, Part B which helps pay for doctors, out-patient hospital care and other medical services (SOCIAL SECURITY- "Medicare", page 4-5, SSA Publication No. 05-10043 March 2001).

Depending on where you live you may be able to get your health care coverage in several ways. Medicare offers the following types of Medicare health plans:
  • The Traditional Plan is a "fee for service" plan. You are charges a fee for each health care service or supply you get. This plan managed by the Federal Government, is available nationwide. You will stay in the Traditional Plan unless you choose to join a Medicare + Choice Plan. Many people in the Traditional Medicare Plan also buy a Medigap (Medicare Supplement Insurance) policy to help pay health care costs that this plan does not cover.
  • Medicare + Choice Plans provide care under contract to Medicare. There are two types of Medicare + Choice Plans. They are available in many parts of the country. Medicare + Choice Plans include Medicare Managed Care Plans (like HMOs and PPOs) and Medicare Private Fee-for-Service Plans. To inquire about changes in your Medicare coverage contact your nearest Social Security office.

(CMS Choosing a Medigap Policy 2003 Guide to Health Insurance for People with Medicare, SOCIAL SECURITY DISABILITY BENEFITS, SOCIAL SECURITY ADMINISTRATION PUBLICATION NO. 05-10029, 2/2003, pages 11-12).

When am I eligible for Medicare?
For those who receive SSDI approval they will begin receiving monthly payments only after five full months of disability and will be entitled to Medicare coverage 24 months after the entitlement date, which is the date that the person becomes eligible for payments. Please recognize that it actually tajkes 29 months from your disablement date until you are eligible for Medicare coverage, not 24 months which is a common point of confusion for recipients.

The Centers for Medicare and Medicaid, CMS, is the agency in charge of the Medicare program. However, the Social Security offices actually enroll you in the program and provide general Medicare information (SOCIAL SECURITY- "Medicare," page 4, SSA Publication No 05-10043, March 2001).

How much does Medicare cost?
If you are under 65 and have been receiving Social Security disability benefits for 24 months, you are eligible for premium-free Medicare hospital insurance Part A. Anyone who is eligible for free Medicare hospital insurance Part A, can enroll in Medicare medical insurance Part B by paying a monthly premium. In addition to the monthly premiums you pay, there are other "out-of-pocket" costs for Medicare. These are the amounts you pay when you actually received medical services, known as "deductibles" and "co-insurance." For example, if you are hospitalized you will be required to pay a deductible amount, and may have to pay co-insurance amounts, depending on how long you stay. If you receive medical services from a doctor, you pay a yearly deductible amount as well as a co-insurance amount for each visit. The monthoy premiums, deductibles and co-insurance for Medicare change each year. You can find out the current amount of these Medicare charges by contacting your local Social Security office or calling Social Security's toll-free number (SOCIAL SECURITY- "Medicare," page 5-7, SSA Publication No 05-10043, March 2001).

Help for low-income Medicare beneficiaries
If you cannot afford to pay your Medicare premiums and other costs, you may be able to get help from your state. You may qualify for a Medicare assitance program as a "Qualified Medicare Beneficiary" (QMB), "Specified Low-Income Medicare Beneficiary" (SLMB or "Qualifying Individual" (QI). These programs are for certain people who are entitled to Medicare and have low income. They may pay some or all of Medicare's premiums and may also pay Medicare deductibles and co-insurance. Only your state can decide if you qualify for help under one of these programs. To find out if you qualify, contact your state or local medical assitance (Medicaid) agency, social service or welfare office (SOCIAL SECURITY- "Medicare," page 8, SSA Publication No 05-10043, March 2001).

Options for Medicare eligible persons with access to Employer Group Health Plans (EGHP)
If you are disabled, eligible for Medicare and are insured through your spouse's employment, you may have several choices as to health coverge:
  • You may opt for both the employer group health plan and Medicare
  • You may opt for Medicare only and decline the employer group health plan
  • You may opt for the employer group health plan and decline Medicare Part B, (remember Medicare Part A is provided automatically)

Each of these options has different consequences which should be considered carefully before deciding which option to choose.

A person may decide to have both the EGHP and Medicare. This will usually give a person dual coverage for many types of services, expand the scope of types of medical care, services and items that may be covered and may provide extra flexibility in obtaining covered health care. Both the EGHP and Medicare should be analyzed to determine if there is additional benefits to having both sets of coverage. For further assistance with these issues contact your State Health Insurance Assitance Program by calling 1-800-Medicare or visit them online at www.medicare.gov.

What is Medicare Supplemental Insurance or a Medigap Policy?
A Medigap policy is a health insurance policy sold by private insurance companies to fill the "gaps" in a Traditional Medicare Plan. There are ten standardized Medigap plans called "A" through "J." Each plan A through J has a different set of benefits. plan A only covers the basic benefits, while Plan J offers the most benefits (www.cms.gov, "Choosing a Medigap Policy 2003 Guide to Health Insurance for People with Medicare").

When I am eligible to purchase Medicare Supplemental Insurance?
Generally, the only time that an insurance company is required to sell a Medicare supplemental policy without medical underwriting, is within the first six months that a person begins coverage with Medicare Part B. After this six-month period, companies usually refuse to sell Medigap policies to people who are disabled. After the first six months of starting Medicare Part B, the next opportunity a disabled person has to purchase a Medigap policy may not be until age 65.

For further assitance with these issues contact your State Health insurance Assitance Program by calling 1-800-Medicare or go to www.medicare.gov.

For further information regarding who pays first if you have other health insurance or coverage, please see the table in Appendix A.