Coverage Options for People with Disabilities

If you have special health care needs—such as being terminally ill, needing assistance with daily activities, receiving regular care at home or in a community setting, residing in a long-term care facility or group home, or having a condition that limits your ability to work—or if you have a disability, you have several health coverage options available.

Current Medicaid or Medicare Recipients If you are already covered by Medicaid or Medicare, you are considered covered under the health care law and do not need a Marketplace plan.

If You Don’t Have Health Coverage You can apply through the Marketplace to see if you qualify for savings on a private health plan or for coverage through Medicaid. Explore the following resources for more detailed information:

• SSDI & Medicare Coverage
• SSI Disability & Medicaid Coverage
• Waiting for a Decision on Disability Status
• No Disability Benefits or Health Coverage

Important Information Under the health care law, all plans must cover treatment for pre-existing conditions from the first day of coverage. This applies to private health plans in the Marketplace, Medicaid, and Medicare. Additionally, Marketplace plans cannot impose annual or lifetime limits on your coverage.

For more details, learn about your rights and protections under the health care law and discover the benefits that Marketplace health plans must offer.

Social Security Disability Insurance (SSDI) & Medicare Coverage

If you receive Social Security Disability Insurance (SSDI), you likely either have Medicare or are waiting for it to begin after a 24-month period. Here’s what you need to know about your coverage options in each case:

If You Have SSDI and Medicare

• Coverage Status: You are considered covered under the health care law, so you won’t face the penalty for lacking coverage.
• Marketplace Plans: You cannot enroll in a Marketplace plan to replace or supplement your Medicare coverage.
• Exception: If you enrolled in a Marketplace plan before qualifying for Medicare, you can retain your Marketplace plan as supplemental insurance. However, you will lose any premium tax credits and other savings associated with your Marketplace plan.

For additional options to supplement Medicare, you can explore other Medicare supplement plans.

If You Have SSDI and Are Waiting for Medicare

• Medicaid Coverage: You may qualify for Medicaid while you await Medicare. You can apply in one of two ways:

  • Online: Create or log in to your Marketplace account, and answer “yes” when asked if you have a disability. Your application will be forwarded to your state Medicaid agency.
  • Directly: Apply directly to your state Medicaid agency. Find contact information for your state on the Medicaid page.

  If eligible, your Medicaid coverage may continue even after you start Medicare.

• Marketplace Coverage: If you are not eligible for Medicaid, you may apply for a private health plan through the Marketplace while you wait for Medicare. You might qualify for lower costs based on your income and household size.

Important Note: When applying for Marketplace coverage, include your SSDI income in your application.

Supplemental Security Income (SSI) Disability & Medicaid Coverage

If you receive Supplemental Security Income (SSI) Disability, you may qualify for Medicaid coverage automatically, or you may need to apply depending on your state’s requirements.

If You Have SSI Disability and Medicaid

• Coverage Status: You are covered under the health care law, so you don’t need a Marketplace plan and won’t face any penalty for lacking coverage.

If You Have SSI Disability and Don’t Have Medicaid

• Automatic Eligibility: In many states, SSI recipients automatically qualify for Medicaid without needing to apply.
• State Requirements:
  • Some States: SSI guarantees Medicaid eligibility, but you must sign up for it.
  • Few States: SSI does not guarantee Medicaid eligibility, though most SSI recipients are still eligible.

Applying for Medicaid

If you have SSI Disability but do not have Medicaid coverage, you can apply for Medicaid in two ways:

1. Direct Application:
2. • Select your state from the menu on the Medicaid page for contact information.
   • Apply directly through your state Medicaid agency.

2. Marketplace Application:

• • Create or log in to your Marketplace account.
  • Answer “yes” when asked if you have a disability. Your application will be forwarded to your state Medicaid office.

Important Note: When completing your Marketplace application, do not include SSI Disability payments when estimating your income.

Additional Information

Some states have expanded their Medicaid programs to cover more individuals. Even if you’re not automatically eligible for Medicaid or have been denied in the past, it’s worth applying.

Waiting for a Disability Status Decision and Lack of Health Insurance

If you're awaiting a decision on your disability status and don't have health insurance, you have several options for coverage.

Apply for Medicaid or a Private Health Plan Through the Marketplace

1.Marketplace Application:

• Create an account or log in to complete your application.
• You'll learn if you qualify for premium tax credits and lower costs on a private health plan based on your household size and income.
• You’ll also find out if you qualify for Medicaid coverage.
• When filling out the application, answer “yes” when asked if you have a disability. We’ll forward your application to your state Medicaid agency. If eligible, they will assist you with enrollment.

2. Direct Medicaid Application:

• Apply for Medicaid directly through your state agency.
• Select your state from the menu on the Medicaid page for contact details.
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Important Notice:

• Disability Status Decision: It can take an unpredictable amount of time to receive a decision about your disability status. Do not assume you will receive Social Security Disability Insurance (SSDI). When estimating your income on the Marketplace application, do not include SSDI payments you anticipate.

If You Receive a Positive SSDI Decision

• Medicare Coverage: If your disability claim is approved, you might need to wait 24 months before Medicare coverage begins. Explore your health coverage options for the interim period before Medicare starts.

If You Receive a Negative SSDI Decision

• Marketplace Application:

  • Reapply for coverage through the Marketplace to determine if you qualify for a private health plan with premium tax credits and lower costs.
  • Your application will also check if you qualify for Medicaid coverage. Answer “yes” when asked about having a disability, and your application will be sent to your state Medicaid agency. If eligible, they will help you enroll.

• Direct Medicaid Application:

  • You can also apply directly for Medicaid through your state agency. For contact information, select your state from the Medicaid page.

By following these steps, you can ensure that you explore all available health coverage options while waiting for your disability status decision.

No Disability Benefits, No Health Coverage

If you have a disability but do not qualify for disability benefits and need health coverage, you still have options through the Health Insurance Marketplace®.

Applying for Coverage Through the Marketplace

1. Marketplace Application:

• Create an account or log in to fill out an application for health coverage.
• Your application will help determine if you qualify for a private health plan with premium tax credits and other savings based on your income.
• It will also assess whether you qualify for Medicaid coverage.

2.Disability-Related Questions:

• During the application process, you may be asked if you:
• Have a physical or mental health condition that limits your ability to work, attend school, or manage daily activities.
• Receive assistance with daily living through personal support, a medical facility, or a nursing home.
• If you answer “yes” to any of these questions, your application will be forwarded to your state Medicaid office to determine if you qualify for Medicaid based on your disability.
• •  
  • The Medicaid office may contact you for additional information about your disability.

Notice:

• Non-Discrimination: Insurance providers offering coverage through the Marketplace cannot deny you coverage or charge higher premiums based on your disability. All Marketplace private insurance plans and Medicaid programs cover pre-existing health conditions from the start of your coverage.

Direct Medicaid Application:

• You can also apply directly for Medicaid through your state agency. For contact details, select your state from the menu on the Medicaid page.

If You Don’t Qualify for Medicaid Based on Your Disability

If Medicaid eligibility based on disability is not an option, you still have two other pathways for health coverage through the Marketplace:

1. Income-Based Medicaid Eligibility:

• You may qualify for Medicaid based solely on your income. Some states have expanded their Medicaid programs to cover all adults with incomes below a certain level. Check if your state has expanded Medicaid and how it may affect you.

2. Marketplace Health Plans:

• You might be eligible to enroll in a health plan through the Health Insurance Marketplace® with premium tax credits and other savings that make coverage more affordable. Eligibility for these savings depends on your household size and income.

The Marketplace Application and Disabilities

When applying for coverage through the Marketplace, you will encounter several questions about disabilities. Here is some information to help you navigate these questions and determine your eligibility for Medicaid or financial assistance with coverage.

Conditions Considered Disabilities

You may be considered disabled if you have one or more of the following conditions:

• Sensory Impairments: You are blind, deaf, or hard of hearing.
• Disability Benefits: You receive Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
• Physical, Cognitive, or Mental Health Conditions: You experience significant difficulties in performing everyday tasks, such as:
  • Handling errands like visiting a doctor’s office or shopping.
  • Concentrating, remembering, or making decisions.
  • Walking or climbing stairs.

Disabilities in Children

For children, the following conditions are considered disabilities:

• They have limited ability to perform typical activities for their age.
• They require more health care than is usual for children of the same age.
• They receive special education services or services under a Section 504 plan.

What Happens if You Indicate You’re Disabled

If you indicate that you have a disability on your Marketplace application, it will be forwarded to your state Medicaid office to determine if you qualify for Medicaid based on your disability. The Medicaid office may contact you for additional information.

• If You Qualify for Medicaid: You may receive Medicaid coverage based on your disability.
• If You Don’t Qualify for Medicaid: You might still be eligible for coverage based on your income or qualify for tax credits.

Even if you are unsure whether your state will qualify you for Medicaid based on your disability, you should still indicate your disability on the application. This ensures you receive the maximum assistance available. Your state will make the final determination on your Medicaid eligibility.

If You Indicate a Disability but Don’t Qualify

If your state determines you either do not qualify for Medicaid based on your disability or does not consider your condition a qualifying disability, you can still purchase health coverage through the Marketplace. Insurance plans cannot deny you coverage or charge higher premiums due to your disability.

If You Do Not Indicate a Disability

If you do not indicate that you have a disability, your application will not be sent to your state Medicaid office on that basis. However, if we later determine you might qualify for Medicaid based on your income, we may send your application for review at that time.

Assistance with Activities of Daily Living

Activities of daily living include tasks such as seeing, hearing, walking, eating, sleeping, standing, lifting, bending, breathing, learning, reading, communicating, thinking, and working.

• If you have a cognitive or mental health condition, you may need assistance with these activities through coaching or instruction.
• If someone needs help solely because of their age and not due to a disability, you should not indicate a need for assistance with daily activities on the application.

More Information About Health Care for People with Disabilities

For more details on Medicare and disability coverage:

• Find Your State’s Medicaid Agency: Locate contact information for your state's Medicaid agency by selecting your state from the menu on the Medicaid page.

Rights and Protections

Learn about your rights and protections under the health care law, including:

• Coverage for pre-existing conditions from day one.
• No annual or lifetime limits on coverage.
• Access to free preventive care.

Assistance and Resources

• Find Local Help: Seek assistance from Navigators and other trained professionals in your community who are experienced with disability issues and can help with your Marketplace application.
• Contact the Marketplace Call Center: Support is available 24/7 through the Marketplace Call Center.

Preview Health Plans

• Explore Options: Review health plans and pricing before you apply to make informed decisions about your coverage.