Special Needs Resource Directory

  • Medicare

    Medicare is a federal health insurance program that serves over 44 million Americans. The program provides health benefits to almost 7 million people younger than age 65 who have a disability or chronic condition. Individuals may be entitled to Medicare if they qualify for Social Security Disability Insurance (SSDI) benefits, or have either End Stage Renal Disease or Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease.

    The Complex Care Center at Cincinnati Children's provides information to help families and health care providers identify sources of financial assistance.
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    Medicare Overview

    Medicare provides certain adults with disabilities with publicly funded health insurance. Medicare helps pay for a broad array of routine, acute, and preventive care, rehabilitation, mental health, home health services and durable medical equipment essential to health and independence. Accessing these services and supports is crucial to enabling millions to avoid far more costly hospitalization and long-term institutionalization. Without Medicare, millions of Americans, especially those with disabilities and chronic conditions, would be unable to obtain or afford any health insurance at all.

    Eligibility

    Because Medicare is a federally funded health insurance program, eligibility is the same in each state and covers:

    • Adult children of parents who currently receive Medicare may also be eligible if the adult child developed a permanent and severe disability before age 22. 
    • Individuals younger than age 65 with permanent disabilities can be automatically enrolled in Medicare after they have received Social Security Disability Insurance (SSDI) payments for 24 months. Individuals, age 18 or older and disabled before age 22, may be eligible to receive benefits under SSDI's "Disabled Adult Child" program if a parent is deceased or is currently receiving retirement or disability benefits. This Disabled Adult Child benefit is paid based on the parent's earning record and the five month waiting period usually required before SSDI begins is waived. The Disabled Adult Child program does not consider the individual's non-employment income, such as an inheritance, a law suit settlement or a spouse's income.
    • Individuals younger than age 65 with end-stage renal disease (ESRD) or Lou Gehrig’s disease are eligible for Medicare benefits as soon as they begin receiving SSDI payments, without having to wait 24 months.
    • Individuals age 65 and older, if they or their spouse made payroll tax contributions for 10 or more years.

    Medicare.gov is the official site for Medicare information and resources

    Medicare and You is a comprehensive publication that has information on all areas of the Medicare program, including a review of what has changed.

    Medicare Eligibility Tool provides information on enrollment and eligibility.

    Kaiser Family Foundation has comprehensive information on Medicare.

    Dual Medicare / Medicaid Coverage

    Medicaid assistance may be available for people with disabilities if they have a waiver or meet Medicaid's low income guidelines. An individual may want to have Medicare in addition to Medicaid because the combination can provide better access to care. Medicaid patients are usually seen only at public health clinics. Private practices would rather treat Medicare patients because of the higher reimbursement rate. This situation becomes even more extreme in adult health care and finding a private physician can be extremely difficult. 

    There are other benefits available to "dual eligibles" who are entitled to both Medicare and Medicaid benefits. Medicaid can help pay for out-of-pocket medical expenses and play a critical role filling in Medicare’s gaps in coverage. It can provide additional services and supplies that are available under the individual's state Medicaid program. Services that are covered by both programs will be paid first by Medicare and the difference by Medicaid, up to the state's payment limit. Medicaid can pay for nursing facility care beyond the 100 day limit covered by Medicare, prescription drugs and monthly premiums, eyeglasses and hearing aids. An individual may want to have Medicare in addition to Medicaid because the combination can provide better access to care. Because Medicare reimbursement is higher than Medicaid, more physicians will accept Medicare patients over Medicaid patients. Most physicians who treat adults accept Medicare but very few accept Medicaid. Medicaid would cover premiums and co-pays for Medicare.

    Centers for Medicare and Medicaid Services information and brochure on dual eligibility.

    Prescription Drug Coverage

    Medicare's prescription drug coverage, sometimes called Medicare Part D, began January 1, 2006. You have a choice of prescription drug insurance plans which are available through private insurance companies. Participation is income driven, therefore you will pay a monthly insurance premium plus a portion of the prescription cost through a co-payment. Medicare prescription insurance plans are open to everyone who is eligible for Medicare.

    CVS Pharmacy has information about the prescription drug coverage under Medicare, as well as a savings calculator to compare plans that would best meet your needs in the area you live.

    Medicare provides an overview of the prescription drug plan.

    Medicare Prescription Drug Plan Finder will help you identify plans through a personalized search or through a search by state.