Can a Child Qualify for Medicare?

You can get Medicare coverage for kids in some limited circumstances.

Medicare defines a “kid” or “child” as anyone who is unmarried and under age 22. Once a child qualifies for Medicare, they can keep the coverage until they’re 26 years old, as long as they remain unmarried and continue to meet the qualifications.

In either qualifying case, a child will need to have a parent or legal guardian who has either earned at least 6 Social Security work credits in the past 3 years or receives Social Security retirement benefits.

Medicare allows children to qualify through biological, adoptive, or stepparents. In the case of stepparents, they’ll need to have been the child’s stepparent for at least 1 year.

Children can also qualify through grandparents and stepgrandparents if they’re acting as the child’s guardian.

Medicare coverage for kids is only intended for children with disabilities. Even then, there are very specific times when a child will be eligible for coverage.

ESRD

Children with ESRD who have a parent who meets the work credit or retirement benefit requirement are eligible for Medicare. In addition to their ESRD diagnosis, they’ll need to meet one of these requirements:

• they need regular dialysis treatments
• they’ve had a kidney transplant

If a child has ESRD and meets either of these requirements, they’ll be eligible for Medicare. Coverage will generally last until 1 year after their last dialysis treatment or 3 years after their kidney transplant.

Coverage can restart if further treatment is needed.

Other disabilities

If a child is over age 20 and has a disability, they’ll need to meet a few additional requirements.

They’ll need to have received Social Security Disability Insurance (SSDI) for at least 24 months before they’re eligible for Medicare. Social Security allows people under age 22 to qualify for SSDI even if they’ve never worked, as long as their disability began before they were 18 years old.

So, to receive Medicare, a child between ages 20 and 22 needs to have been age 18 or younger when their disability began.

Children receiving Medicare through disability also need to meet Social Security’s rules for receiving SSDI. Primarily, their disability must prevent them from working and be expected to last for at least another year.

The parts of Medicare that cover children depend on the way a child has qualified. Kids who qualify for Medicare at age 20 or older and have a disability are able to enroll in any part of Medicare. The only exception to this is Medigap.

Some Medigap companies will sell Medigap gap plans only to Medicare beneficiaries who are age 65 or over. However, other companies will sell to younger beneficiaries. In fact, some states require that Medigap plans are available to all Medicare recipients, regardless of age. The following states require that at least one Medigap plan be available to Medicare enrollees under age 65:

• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• Florida
• Georgia
• Hawaii
• Idaho
• Illinois
• Kansas
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Mississippi
• Montana
• New Hampshire
• New Jersey
• New York
• North Carolina
• Oklahoma
• Oregon
• Pennsylvania
• South Dakota
• Tennessee
• Texas
• Vermont
• Wisconsin

The rules are different for kids who qualify through an ESRD diagnosis. Kids with ESRD can only apply for Medicare parts A, B, and D. The rules for each part of Medicare for kids with ESRD are explained below:

• Part A. Medicare Part A is hospital insurance. Part A covers inpatient services that a child with ESRD might need, including kidney transplants.
• Part B. Medicare Part B is medical insurance. Part B covers doctor’s office visits, outpatient dialysis treatments, medical equipment, and other outpatient services.
• Part C (Medicare Advantage). Medicare Advantage plans combine parts A and B into a single plan. As of 2021, people with ESRD are now eligible to enroll in a broader range of Medicare Advantage plans.
• Part D. Medicare Part D is prescription drug coverage. Children who qualify through their ESRD diagnosis can purchase Part D plans to help pay for prescription drugs.
• Medicare supplement (Medigap). Medigap plans help pay for the out-of-pocket costs of Medicare. Kids who qualify for Medicare because of their ESRD diagnosis aren’t eligible for Medigap.

Medicare for kids has the same costs as Medicare for adults. This means you’ll need to pay all the monthly premiums, deductibles, and copayments that you would for standard Medicare enrollment.

In 2021, costs you can expect to pay include:

• Part A deductible: $1,484 per benefit period
• Part A coinsurance for any hospital or other inpatient stays over 60 days
• standard Part B premium: $148.50
• Part B deductible: $203 for the year
• Part B coinsurance: 20 percent of the Medicare-approved amount for all covered services
• monthly premium for any Medicare Advantage plan you purchase
• monthly premium for any Part D plan you purchase
• prescription drug copayments, as set by your Part D plan
• monthly premium for any Medigap plan you purchase

If a child is eligible for Medicare and you have a limited income, you might qualify for help paying for Medicare. There are several programs that can reduce or even eliminate your costs for Medicare.

The path to enrolling a child in Medicare depends on the reason they’re eligible. Kids between ages 20 and 22 who are eligible through disability will be automatically enrolled in Medicare after receiving 24 months of SSDI payments. They’ll receive enrollment information and their Medicare card in the mail. At this time, they can also enroll in Medicare Advantage, Medicare Part D, or Medigap.

Children eligible through an ESRD diagnosis will need to enroll through Social Security. You can enroll a child by visiting a local Social Security office or by contacting Social Security online. Medicare coverage for kids with ESRD begins their fourth month of dialysis treatment. Depending on when you apply, coverage might backdate and cover treatments a child has already received.

Most kids won’t qualify for Medicare. If a child doesn’t qualify, you have some other health insurance options. Some common ones include:

• Parent’s employer or other private health plans. Kids can stay on their parents’ health coverage until they’re 26 years old. Kids are eligible to stay even if they’re working, married, and not financially dependent on their parents, but coverage ends on their 26th birthday.
• Health Insurance Marketplace plans. Plans you purchase through the Health Insurance Marketplace or your state’s Health Insurance Exchange follow the same rules as insurance through your employer or other private groups. You’re able to add kids who are under age 26 to any plan you buy.
• Children’s Health Insurance Program (CHIP). CHIP is a national program that works with each state’s Medicaid office to provide health insurance to kids. Generally, CHIP is intended for families with limited incomes who make too much money to qualify for Medicaid but not enough money to afford private insurance. Income eligibility requirements vary by state and are based on the federal poverty level.
• Medicaid. Families with limited incomes can qualify for health insurance through Medicaid. Every member of your household, including children, will be eligible if you qualify for Medicaid. Eligibility for Medicaid is based on your income and varies by state.

• Kids are eligible for Medicare if they’re diagnosed with ESRD or are between ages 20 and 22 and receive SSDI.
• Children will need to have a parent who has earned Social Security work credits in the past 3 years or receives Social Security retirement benefits to enroll.
• There are several options available if you don’t qualify for Medicare but still need healthcare coverage for your child.