Medicare for Minors

Medicare Set-Aside Blog on October 26, 2010 | Posted by

Questions:

1) How does a minor become entitled to Medicare?
2) How long do they retain eligibility?
3) When does eligibility begin (i.e. automatically at 18, upon application or at anytime in their life)?
4) Will they become eligible by virtue of age?

ENTITLEMENT: 

In order to qualify for Medicare (title XVIII of the Social Security Act) an individual 1) must qualify for Social Security Act Title II benefits (SSDI benefits) and 2) meet certain other qualifications. An individual qualifies for SSDI benefits by being insured and age 62 or disabled under the Social Security Act definition (with other exceptions).  An individual is “fully insured” by having contributed to the program (paid Social Security taxes) over a sufficiently long period and contributed to the program recently enough to have “disability insured status”. 42 U.S.C 402. The certain other qualifications include either having attained the age of 65 or if not yet 65 having been entitled to disability insurance benefits or child’s insurance benefits by reason of a disability or widow’s/widower’s insurance benefits by reason of a disability. If under age 65 there is a waiting period of 24 months, unless the disability is from end stage renal disease or Lou Gehrig’s Disease (ALS). 42 U.S.C 214 (a) and HI 00801.001.
  
An individual who has end stage renal disease is entitled to coverage under Medicare if he or she is the dependent child (of any age) of an individual who is fully insured regardless of whether the parent is retired, disabled, or deceased. 42 U.S.C. 426-1 and HI 00801.001.

A disabled adult child (one who became disabled before reaching age 22) can receive childhood disability benefits (CDB) based on the earnings record of a wage earner parent who is entitled to retirement or disability benefits or who has died if he or she otherwise qualifies.  The regulations provide: “§404.350 Who is entitled to child’s benefits.  (a) General.  You are entitled to child’s benefits on the earnings record of an insured person who is entitled to old age or disability benefits or who has died if—1) you are the insured person’s child, based upon a relationship described in §§ 404.355-404359; 2) you are dependent on the insured, as defined in §§ 404.360-404.365; 3) you apply, 4) you are unmarried; and 5) you are under age 18; you are 18 years old or older and have a disability that began before you became 22 years old; or you are 18 years or older and qualify for benefits as a full-time student as described in §404.367.” 20 C.F.R. §404.350.

 As noted above, disabled adult children can receive Medicare if they qualify for SSDI benefits and are disabled prior to the age of 22, so called childhood disability benefits (CDB).  A “child” can qualify for SSDI benefits if one of his or her parents is receiving SSDI retirement or disability benefits, or is deceased after becoming insured along with the other listed qualifications. These are called “child” benefits because they are paid on a parent’s Social Security earnings record.  See http://www.ssa.go/pubs/10026.html.

An individual can always become eligible for Medicare based on his or her own earnings record eventually, if they are able to work and become fully insured and/or meet the other qualifications for SSDI benefits.

LENGTH OF ELIGIBILITY:

A disabled adult child who becomes eligible for Medicare based on his or her entitlement to SSDI and disability will be covered by Medicare for as long as they remain under the disability and unmarried. If the individual is capable of working, there is a trial work period available for recipients of SSDI based on disability of 9 months. If after those nine months the individual keeps on working, Medicare would be provided as usual for 93 months or 7 years 9 months. After that period of time (8.5 years total), the individual would need to contribute premiums to continue the Medicare coverage and are deemed an enrollee rather than a beneficiary. HI 00801.126 and See http://www.ssa.gov/disabilityresearch/wi/medicare.htm.

ELIGIBILITY FOR MEDICARE BEGINS:

As noted above, in order for a disabled adult child to become eligible for SSDI benefits, the insured individual upon whose wage earnings the claim will be based, must be retired, be disabled, or have died. This can happen at any time in the disabled adult child’s life.

A minor will not be entitled to receive Medicare, however, prior to the age of 18 unless the child has end stage renal disease. There are some very limited circumstances in which a child might become eligible prior to reaching age 18, but insurance is usually provided for these children through other federally funded programs such as Medicaid and children’s insurance programs. 

The earliest a disabled adult child based on childhood disability benefits (CDB) would become eligible would be age 20 unless the disability is based on Lou Gehrig’s disease (ALS) when the 24 month waiting period ends.  HI 00801.146. The individual must continue to meet the eligibility requirements for SSDI benefits, such as being unmarried and remaining under a disability.

An individual who is able to return to work may become insured by virtue of their own earnings record and the usual rules would then apply based on qualification as the insured person under Social Security Act Title II.