Having health insurance for children with disabilities or special health care needs is essential. And, as our children become adults, they have new options for getting that health insurance. If your child has been receiving Social Security Disability Insurance (SSDI) benefits for 24 months, Medicare might be an option to help pay for medically necessary services, care, and equipment. You can learn more about these benefits on our Social Security Disability Insurance (SSDI) page.
What Is Medicare?
Medicare is the federal health insurance program for people age 65 and older, and for people who have a disability or special health care needs and have been receiving SSDI benefits.
Medicare coverage has 3 important parts:
- Medicare Part A (hospital insurance) covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care costs.
- Medicare Part B (medical insurance) covers certain doctor's services, outpatient hospital care, medical supplies, and preventive services. Your young adult must pay a monthly premium (fee) for Part B.
- Medicare Part D (prescription drug coverage) adds prescription drug coverage to other Medicare health plans that don’t offer this coverage. Insurance companies approved by Medicare offer these plans. Your young adult will pay a monthly premium for Part D. The Texas Department of Insurance (TDI) has more about prescription drug programs in Texas.
Who Can Get Medicare?
- A person who is age 65 and older.
- A person before age 65 who has been receiving Social Security Disability Insurance (SSDI) benefits for 24 months.
- A person who has ALS (Lou Gehrig’s disease) will be automatically enrolled in Medicare Part A and Part B the first month they receive SSDI benefits.
- A person who has end-stage renal disease.
What Does Medicare Offer Children With Disabilities or Special Health Care Needs?
If your child has received SSDI benefits for 24 months, your child can get health insurance through Medicare.
To find out if a specific service or piece of equipment is covered, your child or young adult can talk to their doctor. Or you can search on the Your Medicare Coverage web page.
How Does Medicare Work?
Once your child is approved to get Medicare, they have a choice in Medicare plans. They can pick Original Medicare (Part A and Part B), or they can pick between Medicare Advantage Plans (Part C) offered by different managed care organizations (companies that contract with doctors and other health care professionals into provider networks). Below is a basic comparison of the services.
- Includes Part A and Part B. Part B has a monthly premium and a deductible. There might be times when your child could get better coverage for Part B services from a different health insurance plan. If so, they can choose Part A coverage but not Part B coverage. They can add Part B later if they want.
- Is run directly by the federal government instead of a private insurance company.
- Gives them flexibility. They can work with any doctor, hospital, equipment provider, pharmacy, or other health care provider that accepts Medicare coverage.
- Does not include prescription drug coverage, so they might also want to sign up for a prescription drug coverage plan.
- In Texas, if an adult has Original Medicare and is younger than age 65, they can purchase a limited Medicare Supplement Plan A that will pay some of the health care costs that Original Medicare does not cover, like co-payments and deductibles. Supplement plans, which are also referred to as Medigap, come from private insurance companies, have monthly premiums, and pay in addition to Medicare.
Medicare Advantage Plans
- Include all Part A and Part B benefits.
- Offered by managed care organizations that contract with Medicare. These organizations pay for an adult’s health insurance instead of Medicare paying directly. The adult has to sign up with the plan provider if they want this service instead of Original Medicare.
- Only give a choice of doctors, hospitals, and other providers that are within your plan’s provider network. If your child wants to see someone else, they will have to pay higher fees or even all of the costs.
- Include a monthly premium that is typically higher than a Part B premium.
- Most offer prescription drug coverage.
- Many cover services like vision, hearing, dental, and health and wellness programs that would not be covered under Original Medicare.
- An adult who purchases a Medicare Advantage Plan cannot also purchase a supplemental insurance plan to cover Medicare Advantage deductibles or premiums. Many people pick a Medicare Advantage Plan in place of a Supplemental Plan.
How to Choose a Plan
This is a personal decision based on medical needs, finances, and the plans that are available. You can find and compare plans on the Medicare Plan Finder web page.
Or, if you want help deciding on a plan, the Texas Health and Human Services Commission (HHSC) offers free benefits counseling. Learn more in the Benefits Counseling brochure.
How Does My Child Get Medicare?
Someone who has been receiving SSDI benefits will be automatically signed up for Original Medicare after 24 months. Or they can pick a Medicare Advantage Plan, add on a Prescription Drug plan, or buy a supplemental policy directly from a private insurance company.
If your adult child hasn’t been receiving SSDI benefits but thinks they might be able to get Medicare, they can:
- Once your child has received SSDI benefits for 24 months, they will be automatically enrolled in Original Medicare. Coverage will start the 1st day of their 25th month of SSDI benefits. Their Medicare card should come in the mail about 3 months before this date.
- If your child wants to sign up for a Medicare Advantage Plan or a Prescription Drug Plan, they can start signing up for these up to 3 months before their first day of Medicare coverage would begin.
- If your child picks Medicare Advantage or a Prescription Drug plan, they will need to sign up for that plan on its company’s website.
How Does My Child Change Plans?
If a different Medicare plan will work better for your young adult, they can switch but only at certain times of the year.
- If they want to sign up for or switch between Medicare Advantage, Prescription Drug, or Supplemental Insurance plans, they can do it during the yearly open enrollment period that runs from October 15 to December 7. Work with the new insurance company to make a plan change or sign up. Call your old insurance company, if necessary, to drop coverage.
- If they want to drop a Medicare Advantage Plan and switch to Original Medicare, they can do this from January 1 to February 14. Call the current insurance plan company or 1-800-MEDICARE to make this switch. While making this switch, they can also add a new Prescription Drug plan or Supplemental Plan at the same time.
Can My Child Lose Medicare?
Once your child is approved to get Medicare, they can stay on Medicare for the rest of their life.
If your child started getting Medicare because they were getting SSDI benefits, and then they stop getting SSDI benefits, they can still get Medicare. After 8 ½ years without SSDI benefits, they would have to start paying a premium for Plan A coverage, but they can still stay on Medicare.
Finding Doctors Who Accept Medicare
Not all doctors accept Medicare. Here are some ways to find a doctor that does:
You can also connect with other parents in your area to find out whom they like who accepts Medicare.
Suggested Links to Additional Resources