Medicare coverage for ESRD treatment that is medically necessary is available. The coverage you have will determine the costs you incur.
The body has its own filter system. Your kidneys play a major role in this system. Helping the body from becoming septic, by filtering out any toxins. When your kidneys are unable to do this, they’re not functioning at a level that will support day to day living.
A red flag should go up when your kidneys aren’t working properly. Reason being that, this is a key sign a person has an end-stage renal disease (ESRD).
The Center for Medicare & Medicaid Services (CMS), classifies the end-stage renal disease as “permanent kidney failure that requires a regular course of dialysis or a kidney transplant.” Furthermore, The National Institutes of Health claims diabetes is the leading cause for ESRD.
Medicare Coverage for ESRD (Kidney Disease)
Patients with end-stage renal disease can get help paying for kidney dialysis and kidney transplants through Original Medicare. Medicare is made up of two parts for health-care coverage.
First, Medicare Part A provides coverage for services in a hospital facility that participates in Medicare.
The second half of Original Medicare is Part B. This half of Medicare coverage is your medical insurance. Meaning, Part B covers 80% of the costs for doctors’ visits, diagnostic testing, and screenings, or other services from an outpatient setting. You’re responsible for the remaining 20% of the cost.
Under both Parts A and B, you have the freedom to see any doctor inside your plan’s network. Patients with ESRD are prone to more illness and other health conditions.
This typically results in more prescriptions from your doctors. Medications certainly aren’t cheap and depending on the type, the monthly cost can exhaust your finances.
Fortunately, Medicare offers a plan to avoid these extra medical expenses. Enrolling in a Part D prescription drug plan will help you avoid those monthly costs.
Moreover, you should only enroll in a plan that’s specific to your medical needs, if you haven’t already. Part D will only pay for Medications that are medically necessary.
For coverage to begin, your healthcare provider must be a Medicare enrollee and must accept Medicare assignment. Be sure to check with the provider of your choice and ask if they’re accepting new Medicare patients.
Medicare Advantage coverage and ESRD
Contrarily, you may not enroll in a Medicare Advantage (MA) plan when you have ESRD. While this may be true, there’s a small exception to this rule. The exception is when patients are receiving health plan benefits through the same organization that offers Medicare Advantage Plans.
For instance, let’s say Sally is receiving health benefits through her employer. The employer may use whoever they choose for health insurance coverage. Sally’s primary provider for health care costs and needs is through her employer, who uses the same company that offers Medicare Advantage plans.
If you’re unfamiliar with Advantage plans, they’re another way to get your Original Medicare benefits. Only coverage is done through a private insurance company that works with Medicare.
All MA plans must offer the same benefits as Original Medicare. Many MA plans offer additional benefits, like routine vision and dental services. Prescription drug plans usually come with Advantage plans so you won’t need to enroll in one.
Medicare Special Needs Plan (SNP)
Individuals with ESRD may qualify for a Medicare Special Needs Plan (SNP) if it’s available in their service area. Special Needs plans are a form of Medicare Advantage plan.
This may seem confusing as we said earlier that ESRD patients cannot enroll in Medicare Advantage plans. However, patients suffering from chronic or severe diseases need health coverage more so than the rest of us. So, Medicare offers coverage for ESRD patients under the Special Needs Plan.
Individuals qualifying for SNPs must have either a condition that leaves them with a permanent disability or puts them in a medical institution. Those who have Medicaid entitlements may also qualify for an SNP.
Medicare coverage for dialysis must meet certain requirements in order to start the first month of regular dialysis treatment.
During the first 3 months of a regular course of dialysis, patients must participate in an at-home training program that Medicare offers. After completing the at-home training, Medicare coverage starts the first month that you start regular dialysis treatment.
Some individuals may have the option of finishing dialysis training at-home. Furthermore, your health-care provider may approve you to do treatments in the comfort of your home.
In this case, the dialysis facility is responsible to provide you with monthly visits from your doctor. The facility must also provide all the equipment necessary for at-home treatments.
Medicare doesn’t cover any surgical procedures or services that involve prepping you for dialysis unless a doctor prescribes it medically necessary.
Transportation services to and from the dialysis facility for patients with ESRD may be available depending on your plan.
ESRD Costs with Medicare Coverage
Beneficiaries still pay the 20% coinsurance of the amount allowable amount for all services you’re needing. Then, Medicare pays the leftover 80%.
Medicare Advantage or Supplement Insurance may cover all or just some of the 20% coinsurance cost.
Costs may be different depending on your specific policy or situation. It’s important to make sure you understand your plan and what you’re paying for. Call your plan directly to inquire about your coverage if you’re unsure.
ESRD patients undergoing kidney transplants will have coverage starting the first month of hospital admission. Hospitals must be Medicare-participating to ensure proper coverage.
Your transplant surgery must happen within 2 months after admitting yourself for Medicare to cover the cost. Delaying the transplant is always possible. If this happens, Medicare coverage will start 2 months prior to the month of your new transplant date.
Medicare covers the deductible, coinsurance, and any other costs for the kidney donor’s stay at the hospital. Neither you nor your donor will be responsible for those costs.
Part D Prescriptions and ESRD
After having a kidney transplant, you’ll be taking prescription drugs for the rest of your life. These post kidney transplant drugs are formally known as transplant (immunosuppressive) drugs.
Your recovery and overall health rely on taking these drugs. They work by reducing the chances of your body rejecting the new kidney.
Medicare Part B covers these immunosuppressive drugs, and other drugs relating to ESRD under certain circumstances. Part B will cover costs when you receive them in an outpatient setting by a health-care professional.
Medicare Part D covers your prescription drugs if you’re filling them at a pharmacy and taking the medications at home. Part D covers the medications taken without assistance from a medical professional.
This includes Part D coverage for oral medications and any medications relating to ESRD.
Determine Medicare Eligibility
Age is not a determining factor for Medicare eligibility when your kidneys stop working. When your kidneys fail, dialysis is medically necessary on a regular basis.
Ask yourself some of the following questions. If you answer yes to any, then file an application to get the process going. There may be waiting periods that apply, so it’s important not to procrastinate.
Do you need regular dialysis? Have you had a kidney transplant? Did you work the proper amount of time under Social Security (SS) or the Railroad Retirement Board (RRB)? Or, did you work as a government employee for some time?
Those receiving SS or RRB benefits may also qualify. Medicare coverage is available to the spouse or dependent child of a person who meets the requirements.
Identifying and Treating At-Risk People Sooner
An executive order has begun that will select a payment model that tests innovations in compensations for kidney care providers; this payment would reflect kidney patient costs as well as the quality outcome.
This model should help prevent the onset of kidney failure and prevent unnecessary hospital visits. Additionally, this model will aim to create incentives for beneficiaries with advanced stages of kidney disease that don’t receive dialysis.
Flexible advance payment options for nephrologists would be available and this would better support coordination of care.
Get Assistance With Medicare Coverage for ESRD
If you don’t meet the requirements to qualify for Medicare coverage, your state may provide alternative options that might help pay for your dialysis treatments.
Contact your local Social Security office for further information. You may qualify for other programs or you may just need to speak with an agent to be sure. Working with an agent is like having a safety net.
Our agents specialize in Medicare knowledge. As things are constantly changing and updating within the Medicare program, it’s easy to miss something.
Give us a call today at the number listed above or fill out a rate form online, here. Let us help you. We can discuss plan options and give you the answers you need for the best health-care possible.