Medicare with SSDI covers some medical costs, but not all of them

If you receive SSDI, you become may be able to access for Medicare after you have been on the program for 24 months. Medicare is health insurance run by the federal government, and it has four parts: Part A (hospital care), Part B (doctor visits and outpatient services), Part D (prescription drugs), and Part C (an alternative plan). Each part covers different things, and each has costs you pay out of your own money. Medicare does not cover dental work, vision care, hearing aids, or long-term care in a nursing home — those gaps are important to know about.

The word "everything" is the key misunderstanding. Medicare pays its share of covered services, but you still pay your share. You might owe a monthly premium for Part B, a yearly deductible before coverage starts, a copay each time you see a doctor, or coinsurance (a percentage of the cost). If you have low income, you may may have access to for Medicaid at the same time, which can help pay those costs — but that is a separate program with its own rules.

Key Takeaways

  • Medicare Part A covers hospital stays, skilled nursing care after hospitalization, and some home health services, but you pay a deductible and coinsurance.
  • Medicare Part B covers doctor visits, lab work, X-rays, and outpatient care, but requires a monthly premium and you pay 20 percent coinsurance after the deductible.
  • Medicare Part D covers prescription drugs through a private insurance company, and the drugs covered and your costs depend on which plan you choose.
  • Dental, vision, hearing aids, and nursing home care are not covered by Medicare, though some Medicare Advantage plans (Part C) offer limited dental or vision benefits.
  • If your income is low enough, Medicaid can pay Medicare costs you cannot afford, but you must meet your state's income and resource limits.

What Medicare Part A covers and what you pay

Part A covers inpatient hospital care — meaning you stay overnight in a hospital bed. It also covers skilled nursing facility care if you need rehabilitation after a hospital stay (such as physical therapy), and some home health services if you are homebound and a doctor orders them. Part A does not cover custodial care, which is help with daily living tasks like bathing or dressing if that is all you need.

You do not pay a monthly premium for Part A if you or your spouse paid Medicare taxes while working. However, you do pay a deductible each time you are admitted to the hospital — in 2024, that deductible is $1,696 for days 1 through 60 of a hospital stay. After 60 days, you pay coinsurance (a daily amount) for days 61 through 90. If you stay longer than 90 days, costs rise sharply. For skilled nursing care, you pay nothing for the first 20 days, then coinsurance for days 21 through 100.

What Medicare Part B covers and what you pay

Part B covers doctor visits, preventive care (like cancer screenings and vaccines), lab work, X-rays, physical therapy, and outpatient surgery. It also covers durable medical equipment like wheelchairs or oxygen if a doctor prescribes it. Part B does not cover routine dental care, eye exams for glasses or contacts, or hearing aids.

You pay a monthly premium for Part B — the standard amount in 2024 is $164.90, though it may be higher if your income was above a certain level two years ago. You also pay an annual deductible (currently $240) before Part B coverage begins. After you meet the deductible, you typically pay 20 percent of the cost of covered services, and the provider or supplier bills Medicare for the other 80 percent. If a doctor does not accept Medicare, you may owe more.

What Medicare Part D covers and how to choose a plan

Part D is prescription drug coverage. It is run by private insurance companies, not by Medicare directly, so the drugs covered and the costs vary depending on which plan you choose. Each plan has a formulary — a list of drugs it covers — and drugs are sorted into tiers with different copays. A drug on tier 1 might cost $5, while the same drug on tier 3 might cost $50.

You pay a monthly premium for Part D, which varies by plan. You also pay a deductible (usually $545 in 2024, though some plans have no deductible). After you meet the deductible, you pay your copay or coinsurance for each prescription. If your yearly drug costs reach a certain amount, you enter the "donut hole" — a coverage gap where you pay a larger share until your out-of-pocket costs hit a yearly maximum. The rules and costs change each year, so it is worth reviewing your plan every October during the annual enrollment period.

What Medicare does not cover

Medicare has significant gaps. It does not cover dental work — no cleanings, fillings, root canals, or dentures. It does not cover routine eye exams, glasses, or contact lenses. It does not cover hearing aids or hearing exams. It does not cover long-term care in a nursing home if you need help with daily living (though it does cover short-term skilled nursing care after a hospital stay). It does not cover most cosmetic surgery, acupuncture, or weight-loss surgery.

These gaps can be expensive. A single hearing aid can cost $2,000 to $6,000. Dental work can run into thousands of dollars. If you need nursing home care for years, Medicare will not pay for it — you would need to pay out of pocket or meet your state's rules for Medicaid coverage of long-term care. Some people buy a Medigap policy (supplemental insurance) to cover some of these gaps, though Medigap does not cover dental, vision, or hearing aids either.

How Medicaid can help pay Medicare costs

If your income is low and your resources (savings, property) are below your state's limit, you may be may be able to access for both Medicare and Medicaid at the same time. When you have both, Medicaid can pay your Medicare premiums, deductibles, and coinsurance — meaning you owe less out of your own pocket. Medicaid can also cover some services Medicare does not, such as dental care and nursing home care, though coverage varies by state.

The income and resource limits for Medicaid are different in every state. Some states are more generous than others. To find out whether you may have access to in your state, contact your state Medicaid office or call 211 for a referral to a local benefits counselor. A counselor can review your situation and tell you what you might be able to get.

Medicare Advantage plans and what they add

Medicare Advantage, also called Part C, is an alternative to Original Medicare (Parts A and B). Instead of going to any doctor who accepts Medicare, you choose a plan run by a private insurance company. The plan must cover everything Original Medicare covers, but it can add benefits like dental, vision, or hearing aid coverage — though the coverage is usually limited. For example, a plan might cover one dental cleaning per year, not all dental work.

Medicare Advantage plans often have lower premiums than Part B plus a Medigap policy, but they have networks (you must use doctors in the plan) and prior authorization requirements (the plan must approve certain treatments before you get them). If you travel or move, you may lose access to your doctors. The plans change their benefits and networks every year, so you need to review your coverage during the annual enrollment period.

Frequently Asked Questions

Do I have to take Medicare when I become may be able to access after 24 months on SSDI?

No, you do not have to take it, but there is usually a penalty if you delay. If you do not sign up for Part B when you first become may be able to access, your monthly premium will be 10 percent higher for each year you waited. The same applies to Part D and prescription drugs. It is generally better to enroll even if you have other insurance.

What if I cannot afford the Medicare premiums and deductibles?

If your income is low, Medicaid may pay your Medicare costs. You can also ask about a Part B premium subsidy or Extra Help with Part D costs — these are federal programs for people with low income. A benefits counselor can tell you whether you may have access to and help you explore.

Does Medicare cover mental health care and therapy?

Yes, Medicare Part B covers mental health visits with a psychiatrist, psychologist, or licensed counselor. You pay the same 20 percent coinsurance as for other doctor visits after you meet your deductible. Some therapists do not accept Medicare, so ask before you schedule an appointment.

Can I use my SSDI to pay for things Medicare does not cover?

Yes, your SSDI payment is yours to spend as you choose. Many people use part of their SSDI to pay for dental work, glasses, or hearing aids that Medicare does not cover. If your income is very low, you might also look into local programs or nonprofits that help pay for these services.

What happens to my Medicare if I go back to work and leave SSDI?

If you work and your earnings are high enough, your SSDI will stop. However, you can usually keep Medicare for a period of time after SSDI ends — the length depends on your situation. Contact Social Security before you start work to understand how it will affect your coverage.