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Medicare eligibility for those under 65

Many people think of Medicare as a government healthcare program for Americans and legal permanent residents (of at least five continuous years) who are at least 65 years old. But some people qualify for Medicare before age 65. In fact, more than 8 million current Medicare recipients are under the age of 65. Understanding who comprises this market and how you can best meet their insurance needs could open your business up to new potential clients!

Who Exactly Qualifies for Under- 65 Medicare?

Put simply, under 65 individuals who qualify for Medicare are those who have been receiving either Social Security Disability Income (SSDI) or Railroad Retirement Board (RRB) disability benefits for at least 24 months. These individuals must also have a medical professional determine that the individual is unable to work as a result of their disability whether physical or mental and that the disability will last at least 12 months. These individuals typically are required to work a certain number of work credits to qualify for either SSDI or RRB benefits, except in unique circumstances, when work credits can be allowed to be transferred to a family relative.

Which Disabilities Specifically Qualify Individuals for Medicare?

The two diagnoses that right-off-the-bat qualify someone for Medicare under the age of 65 are end-stage renal disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS), coverage beginning after their first SSDI or RRRB disability check.

Some of the more common conditions that can qualify individuals for under- 65 Medicare include, but are not limited to:

  • Cerebral Palsy

  • Cystic Fibrosis

  • Multiple Sclerosis

  • Neurodevelopmental Disorders

  • Heart Disease

  • Chronic Liver Failure

A More Detailed Look

Given the nature of under- 65 Medicare recipient circumstances, finding work and holding a steady income can be difficult. Therefore many of these individuals also receive Medicaid (25% more than Medicare receiving senior) as well as non- Medicaid financial assistance, reflected clearly by the fact that 60% of under- 65 Medicare beneficiaries have an annual income below $20,000, twice as many enrollees with low incomes than found in the senior Medicare recipients!

Medicare Advantage Sales Opportunity

Those qualifying for Medicare under the age of 65 will have very specific health needs, given the limited flexibility of traditional Medicare, selling Medicare Advantage plans to these individuals is a very real opportunity. Especially considering that as of 2020, more under 65 Medicare beneficiaries were enrolled into Medicare Advantage than traditional Medicare, with the growth of MA enrollees from 2013- 2019 of 60 percent!

With the uniquely special needs of this group of beneficiaries, Special Needs Plans (SNPs) often times fit their needs very effectively. Both D-SNPS and C-SNPS can apply to individuals in this group given their often low income qualifying them for Medicaid and Medicare and in many cases the chronic nature of their disabilities. In fact, according to AHIP, the under- 65 eligibles comprised 43% of all D-SNP beneficiaries and 35% of the MA market! This presents a tremendous opportunity to agents selling MA and DSNP plans, allowing for additional MA sales during AEP and DSNP enrollments the rest of the year.

The Other Major Opportunity

Part D plans present another major sales opportunity for agents, among the under- 65 Medicare-eligible groups. Below are some quick stats to emphasize this point:

  • 75% are enrolled in a Part D plan, compared to 63% of seniors

  • 55% of under- 65 beneficiaries receive Part D LIS, only 16% of senior beneficiaries do

  • Under- 65 Medicare recipients also spend almost $3,000 more/year on Part D drugs than those over 65

Part D plans are another great opportunity for agents to reach out to this unique group, with a number of plans that can be fitted to the specific needs of each under 65 individual, you can ensure that they are getting the prescription drug coverage they need while adding to your portfolio!

A Mutual Opportunity

As an agent, your number one goal for yourself is adding new business, whether via Medicare Advantage, Special Needs Plans, or Part D plans, reaching out to the under- 65 Medicare-eligible population provides opportunities to sell all three! There are few other populations in as much need of healthcare coverage as those eligible for Medicare under 65, improve the quality of their lives while adding to your portfolio and create a client relationship to last.

For more information visit:


Check out the Medicare Advantage and Special Needs Plans we offer on Producer Academy

If you are not an agent partner with Keystone Advisors, call us at 346-233-1992 to speak with one of our agent managers.

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