Medicare Under 65 in Washington: Disability, ALS, Kidney Failure and the Medigap Gap

127,100 Washingtonians had Medicare before age 65 in June 2026, according to CMS enrollment data. That's 8.0% of everyone on Medicare in the state (CMS Medicare Monthly Enrollment). Nationally the share is 9.4%.

Most of them got there the same way: two years of Social Security Disability Insurance (SSDI). A smaller group got Medicare because of ALS or permanent kidney failure. The rules for getting in are federal. What happens next isn't. Washington does not require insurers to sell a Medicare Supplement (Medigap) policy to anyone under 65. Thirty-three states require insurers to offer at least one kind of Medigap policy to people under 65 (some only to those eligible by disability or ESRD), including Oregon and Idaho. Washington isn't on the list. That one difference shapes most coverage decisions a younger Washington enrollee makes.

Source: CMS Medicare Monthly Enrollment, June 2026 (shares computed); CMS, Choosing a Medigap Policy (2026); CMS 2026 Part A and B fact sheet.

Three ways in before 65

Before 65 there are three main routes: a disability that's been paying Social Security (or certain Railroad Retirement Board) disability benefits for 24 months, ALS, or end-stage renal disease. Medicare.gov and the Washington Office of the Insurance Commissioner (OIC) describe the same three.

Source: Medicare.gov, other paths to Medicare; Medicare & You 2027, pp. 15-16; 42 U.S.C. 426(b), (h); 42 CFR 406.12; Medicare.gov, ESRD.

The 24-month rule for SSDI and railroad disability

The federal statute, 42 U.S.C. 426(b), gives Part A to anyone under 65 who has been entitled to Social Security disability benefits for 24 calendar months, starting with the 25th month. The same rule covers people getting disabled adult child benefits, disabled widow's or widower's benefits, and qualified railroad disability annuitants. Medicare & You 2027 says you get both Part A and Part B automatically at that point.

The detail people miss: the 24 months count months of entitlement to benefits, not months since you got sick or stopped working. And SSDI itself has a five-month waiting period before the first payable month (42 U.S.C. 423(c)(2)). Put the two together and Medicare usually starts around two and a half years after the onset date Social Security sets. Here's how that looks on a calendar.

Source: illustration built from 42 U.S.C. 423(a)(1), (c)(2) and 42 U.S.C. 426(b); card timing from Medicare & You 2027, p. 15. Your actual dates depend on the onset date and entitlement months Social Security sets.

Earlier disability periods can count. If you were on SSDI before, those months can count toward the 24, as long as the earlier period didn't end too long ago (60 months for most workers, 84 for disabled widows, widowers and adult children). If the new disability is the same as or directly related to the old one, the earlier months count no matter when they ended (42 U.S.C. 426(f)).

Part B is automatic, but you can turn it down. The card comes with instructions. If you don't want Part B, you have to tell Social Security before the start date on the card. If you do nothing, you keep Part B and the premium comes out of your benefit (Medicare & You 2027, p. 15). Turn it down only if you have other coverage that works with Medicare, because signing up later without a Special Enrollment Period can add 10% to your premium for each full 12-month period you could have had it but didn't (same guide, p. 23).

Part A is premium-free. If Medicare comes to you automatically after 24 months of disability benefits, you don't pay a Part A premium.

ALS: no waiting

For ALS, both waits are gone. 42 U.S.C. 426(h) makes Medicare start with the first month of disability entitlement instead of the 25th. And a 2020 federal law (Public Law 116-250, signed December 22, 2020) removed SSDI's five-month waiting period for people medically determined to have ALS. Under the law's effective-date note, that applies to applications approved after the date five months before enactment (42 U.S.C. 423).

In practice: apply for SSDI as soon as the diagnosis is made. Medicare Part A and Part B begin the same month the disability benefits do.

Kidney failure (ESRD): you have to sign up

ESRD works differently from the other two paths. It doesn't depend on SSDI, it isn't automatic, and Medicare can end. Per Medicare.gov, you can get Medicare at any age if your kidneys no longer work, you need regular dialysis or have had a kidney transplant, and you (or your spouse, or a parent if you're a dependent child) have worked the required time under Social Security, the Railroad Retirement Board or as a government employee, or already get or qualify for Social Security or Railroad Retirement benefits.

You enroll through Social Security (1-800-772-1213, TTY 1-800-325-0778). Your dialysis facility fills out a form called the ESRD Medical Evidence Report (CMS-2728) and sends it in. If you don't sign up right away, coverage can reach back up to 12 months before the month you apply.

Source: Medicare.gov, End-Stage Renal Disease; Medicare & You 2027, p. 16.

Coverage restarts if you go back on dialysis or get another transplant within those windows. After a successful transplant, Medicare also has a separate benefit that covers only immunosuppressive drugs once the 36 months end, for people without certain other coverage. In 2026 it costs $121.60 a month (more at higher incomes) with a $283 deductible (Medicare & You 2027, p. 55).

Two more rules matter for kidney patients. If you have an employer or union plan, it pays first for a 30-month coordination period, and Medicare.gov says you can wait until that period ends to sign up without a higher Part B premium. And since January 1, 2021, people with ESRD can choose a Medicare Advantage plan instead of Original Medicare; the 21st Century Cures Act changed that (CMS fact sheet; 42 CFR 422.50).

Who's on Medicare under 65 in Washington

120,000140,000160,000180,000

127,100

2013201620192022Jun 2026

Source: CMS Medicare Monthly Enrollment (state rows, "disabled" beneficiaries).

Show the numbers

	Under 65 (disability and/or ESRD)
2013	168,519
2014	172,376
2015	174,950
2016	175,619
2017	174,715
2018	173,142
2019	169,800
2020	164,620
2021	158,478
2022	151,229
2023	144,491
2024	138,557
2025	133,417
Jun 2026	127,100

• Washington
• United States

0.0%5.0%10.0%15.0%20.0%

20132016201920222025Jun 2026

Source: CMS Medicare Monthly Enrollment; shares computed from state and national rows.

Show the numbers

	Washington	United States
2013	15.3%	16.5%
2016	14.2%	15.5%
2019	12.5%	13.9%
2022	10.4%	11.9%
2025	8.6%	10.0%
Jun 2026	8.0%	9.4%

The count peaked in 2016 at 175,619 and has fallen every year since, down 48,519 by June 2026, with Washington's share below the national one in every year shown. CMS's data doesn't say why, and I won't guess.

About 75% of Washington's under-65 enrollees (95,010) are 45 to 64, 30,568 are 25 to 44, and 1,522 are under 25. Roughly 3,600 have ESRD (some of them also have a disability). For many of them, Medicare is the main coverage for years before 65, which is why the Medigap question matters.

Washington's Medigap gap

Original Medicare leaves you with deductibles, usually 20% of the Medicare-approved amount for Part B services, and no yearly limit on out-of-pocket costs unless you add supplemental coverage (Medicare & You 2027, p. 11). Medigap is the supplemental coverage built for that. Under 65, you may not be able to buy it.

The federal rule, from CMS's Choosing a Medigap Policy: federal law generally doesn't require insurance companies to sell Medigap policies to people under 65. Thirty-three states require insurers to offer at least one kind of Medigap policy to people under 65 (some only to those eligible by disability or ESRD), including Oregon and Idaho. Washington isn't on the list (CMS 02110, p. 32). The OIC's Medigap handbook confirms it in plain words: Washington state doesn't require insurers to offer Medigap plans to people on Medicare under age 65, but you can contact insurers directly to see if they might sell you a Medigap.

So before 65, whether you can buy a Medigap policy here is up to each insurer. Here's what the state's rules do and don't do.

Source: as listed in each row; state list from CMS, Choosing a Medigap Policy, p. 32.

The switching right helps only after you're in. RCW 48.66.045(2) requires insurers to issue their standardized plans B, D, G, high-deductible G, K, L, M or N, without health questions, to a Washington resident who became eligible for Medicare on or after January 1, 2020 by reason of age, disability, or end-stage renal disease, when the new policy replaces another Medigap policy (there's a parallel list for people eligible before 2020). It's a year-round switching right, and it doesn't force anyone to sell you a first policy. But once you're in, you have the same right to change plans as a 65-year-old.

A price difference is allowed. Washington Medigap rates are community-rated, but the law lets an insurer keep two rating pools: one for people eligible by age, one for people eligible by disability or ESRD. Medicare & You 2027 (p. 81) says that if you're able to buy one under 65, it may cost more. CMS's Medigap guide (p. 32) goes further: under-65 policies will probably cost more, and insurers will probably use medical underwriting (health questions).

WSHIP is a backstop with conditions. The OIC says the Washington State Health Insurance Pool sells its Medicare Basic plan to people on Medicare who've been rejected by a Medicare Supplement plan for health reasons, and to people who live where plans don't offer coverage. The statute, RCW 48.41.100, adds conditions, including whether you have what it calls a reasonable choice of comprehensive Medicare Advantage plans in your county. Don't count on WSHIP until you've checked your eligibility with WSHIP or SHIBA.

Guaranteed-issue rights after losing coverage are a question for SHIBA. Washington's guaranteed-issue law (RCW 48.66.055) covers people who lose certain coverage, but whether it gets someone under 65 a policy from an insurer that doesn't sell to that age group isn't clear from the text. If you lose coverage, call SHIBA or the OIC before the deadline passes and ask whether a guaranteed-issue right applies to you.

The other route is Medicare Advantage. Eligibility rules require Part A and Part B and residence in the plan's service area, with no minimum age (42 CFR 422.50), and Medicare & You 2027 says you can join a Medicare Advantage Plan when you first become eligible for Medicare. It's a different trade-off from Original Medicare plus a supplement: Medicare Advantage plans have a yearly limit on what you pay for covered services, but they may require prior authorization, which Original Medicare in most cases doesn't (Medicare & You 2027, pp. 11-12). My Medicare Supplement in Washington guide covers how Medigap works here, and the Medicare Advantage side is on my Washington Medicare page. If you have Apple Health too, read how Apple Health and Medicare work together first, because that changes the math.

If you or your spouse still has a job-based plan

If you're also on a spouse's or family member's job-based plan, who pays first depends on employer size. For people under 65 with a disability the line is 100 employees, not the 20-employee line that applies at 65 and over.

Source: Medicare & You 2027, p. 21; Medicare.gov, ESRD.

If the employer plan pays first and you delay Part B, you generally get a Special Enrollment Period later. One catch for disabled enrollees: if the coverage comes from a non-spouse family member's current job, that employer must be part of a large group health plan for the Special Enrollment Period to apply (Medicare.gov). My post on Medicare and employer coverage walks through the timing.

What it costs in 2026

Source: CMS, 2026 Medicare Parts A & B premiums and deductibles; Medicare & You 2027, pp. 15, 55. Higher-income enrollees pay more for Part B.

These are the same amounts people over 65 pay. CMS hasn't published the 2027 figures yet; it usually announces them in the fall, and last year's came out November 14. I'm tracking that in my Part B premium 2027 post.

If your income is limited, a Medicare Savings Program through Washington's Health Care Authority can pay the Part B premium and, at the lowest income tier, deductibles and coinsurance too. Washington has no asset test for these programs. The limits are in my Medicare Savings Program in Washington post.

Going back to work

A job usually doesn't cost you Medicare, at least not quickly.

Extended Medicare. According to Social Security's Red Book, after your nine-month Trial Work Period ends, premium-free Part A continues for at least 93 consecutive months, starting the month after the last trial work month. That's more than seven and a half years. Part B and Part D continue too if you stay enrolled and keep paying.

Medicare buy-in. If premium-free Part A does end because of work, and you're still disabled and under 65, you can keep Medicare by paying for it (Red Book). In 2026, Part A costs $565 a month, or $311 if you have 30 or more quarters of coverage (CMS), and Part B is $202.90. You can't buy Part B without Part A.

QDWI in Washington. The Qualified Disabled and Working Individuals program pays the Part A premium. Under WAC 182-517-0100 you must be under 65, employed and meet the disability rules, with countable income above 138% but not more than 200% of the federal poverty level; there's no resource test. Apply through HCA or Washington Connection.

Apple Health for Workers with Disabilities (HWD). HCA's HWD program covers working people with a disability, has no resource or income limit, and charges a monthly premium of no more than 7.5% of total income (American Indians and Alaska Natives are exempt). You must be working, at least 16, and not eligible for other Apple Health programs. HCA's page lists DSHS Home and Community Services (1-800-871-9275) for the paper application. Ask how HWD would work alongside your Medicare before you count on it.

What changes at 65

Your Medicare doesn't stop at 65; it switches from disability-based to age-based. Three things come with that.

A new enrollment window. Social Security gives you a new Initial Enrollment Period based on turning 65.

A Part B penalty can go away. If you've been paying a Part B late-enrollment surcharge from your under-65 years, Social Security's operating manual says the surcharge is eliminated once you're entitled at 65, because of that new enrollment period (SSA POMS HI 00805.281).

Your Medigap open enrollment finally arrives. CMS says that even if you already have Part B, you still get a Medigap Open Enrollment Period when you turn 65, and during it insurers can't refuse to sell you a policy or charge you more because of a disability or other health problem (CMS 02110, p. 32). Washington writes the same protection into RCW 48.66.025: six months starting with the first month you're both 65 and enrolled in Part B.

That's the date I'd put on the calendar years ahead. For someone who couldn't buy Medigap at 50 or 60, those six months are the window Washington law sets aside for everyone turning 65. Outside it, the open-enrollment protection in RCW 48.66.025 doesn't apply, so a first policy can come with health questions. My Washington Medicare Supplement page lays out the standardized plans.

FAQ

Can you get Medicare under 65?

Yes, in three ways: after 24 months of Social Security (or certain Railroad Retirement Board) disability benefits, from the first month of disability benefits if you have ALS, or at any age if you have end-stage renal disease and meet the work requirements.

What disabilities qualify for Medicare under 65?

Any disability that gets you Social Security disability benefits counts once you've been entitled to those benefits for 24 months. ALS and end-stage renal disease have their own faster rules.

Can I buy a Medigap policy under 65 in Washington?

Maybe, but no insurer has to sell you one. Washington does not require insurers to offer Medigap to people under 65; the OIC says you can contact insurers directly. Your protected Medigap open enrollment starts when you're 65 and enrolled in Part B.

Does Medicare under 65 cost the same as at 65?

The government-set amounts are the same: in 2026, Part A is premium-free for people who get it automatically, the standard Part B premium is $202.90 a month and the Part B deductible is $283.

Federal Medicare rules, Washington law and your own policy wording control what applies to you. Confirm your situation with Social Security, SHIBA, the Washington OIC or a licensed agent, and talk to an attorney about legal questions.

Sources

1. Medicare.gov: Other paths to Medicare (disability, ALS, ESRD)
2. CMS: Medicare & You 2027
3. Medicare.gov: End-Stage Renal Disease (ESRD)
4. Medicare.gov: Joining a plan
5. Medicare.gov: When does Medicare coverage start (Special Enrollment Period)
6. CMS: Choosing a Medigap Policy (Product No. 02110)
7. 42 U.S.C. 426: Entitlement to hospital insurance benefits
8. 42 U.S.C. 423: Disability insurance benefit payments
9. 42 CFR 406.12: Individual under age 65 entitled on the basis of disability
10. 42 CFR 422.50: Eligibility to elect an MA plan
11. CMS: Contract Year 2021 MA and Part D final rule (CMS-4190-F1) fact sheet
12. CMS: 2026 Medicare Parts A & B premiums and deductibles
13. CMS: Medicare Monthly Enrollment data
14. SSA POMS HI 00805.281
15. SSA Red Book: Extended Medicare coverage
16. SSA Red Book: Medicare buy-in
17. Washington OIC: Medicare options for people with disabilities
18. Washington OIC: What you need to know about Medigap plans (2026)
19. Washington OIC: Medigap coverage and costs
20. Washington OIC: Washington State Health Insurance Pool (WSHIP)
21. RCW 48.66.025: Medicare supplement open enrollment
22. RCW 48.66.045: Standardized plans, replacement and rating
23. RCW 48.66.055: Guaranteed issue
24. RCW 48.41.100: WSHIP eligibility
25. WAC 284-66-130: Required application statements
26. WAC 284-66-243: Medicare supplement policy forms
27. WAC 182-517-0100: Medicare savings programs
28. Washington HCA: Medicare Savings Program
29. Washington HCA: Apple Health for Workers with Disabilities