Medicare coverage for ESRD treatment that is medically necessary is available. The coverage you have will determine the costs you incur.
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.” Further, The National Institutes of Health claims diabetes is the leading cause of ESRD.
End-Stage Renal Disease is one of two conditions that qualify for immediate Medicare. It doesn’t matter the age either.
Medicare pays most of the cost of dialysis, transplants, and other healthcare that ERSD patients need.
People with ESRD can get Medicare coverage, even if they aren’t 65 yet. Unlike people who qualify for because of disabilities, ERSD patients don’t wait 24 months for benefits.
If your kidneys aren’t working, you qualify for Medicare if you can answer “YES” to any of these questions:
- Have you worked enough to be eligible for Social Security or Railroad Retirement benefits?
- Are you already receiving, or eligible for, Social Security or Railroad Retirement benefits?
- Are you the spouse or child of someone who meets one of the first two criteria?
End-Stage Renal Disease and Medicare
If you have ERSD, Medicare covers dialysis and transplants. Your Medicare benefits also extend to healthcare that’s not related to your kidneys.
Depending on the service, and whether you have extra insurance, you may pay some costs.
In general, Part A covers procedures and drugs you take while an inpatient in a hospital. Part A has a $1408 deductible in 2020.
After that, your first 60 days in the hospital are 100% covered.
If you haven’t been admitted to the hospital, your care falls under Part B. Part B has a small annual deductible.
Medicare pays 80% of the cost. Including doctor visits, dialysis, and drugs administered at a doctor’s office. You pay the other 20%.
Part D covers prescriptions that you take at home.
ESRD and Medicare Advantage Coverage
If you have Medicare Advantage and ERSD, you may be surprised to discover that your plan won’t cover kidney disease treatment.
Most Medicare Advantage plans don’t, but you do have options. Let’s say Mrs. Davenport enrolled in an Advantage plan a few years ago.
Her doctor recently diagnosed her with ESRD, and her current policy doesn’t cover her. She has to wait until the Annual Enrollment Period to make changes.
At that time, she can switch to Medicare, which covers her treatment. She can also choose to join a Medicare Advantage Special Needs Plan.
Special Needs Plans are for people with chronic issues. Although, it’s important to keep in mind that not all plans are available in all counties.
But, if a plan is available, you can enroll outside of the Annual Enrollment Period because eligibility for the plan qualifies you for a Special Enrollment Period.
Tip: Work with an agent to find out if any companies in your area offer a Special Needs Plan for you.
ESRD and Employer Health Insurance Coverage
If you have ERSD and employer health insurance, you must decide whether to enroll in Medicare. There are several factors to consider.
Those with Medicare and employer coverage, the employer is primary for the first 30 months you’re eligible for Medicare.
Meaning, the employer insurance pays first, and Medicare may pick up costs that the employer doesn’t pay.
After the 30th month, Medicare becomes primary, and employer insurance won’t pay. If you drop employer coverage, Medicare pays only 80%.
You may be able to switch from your employer’s insurance to an Advantage plan offered by the same company.
Tip: Before making a decision, understand the benefits and restrictions of both Medicare and the employer plan.
Medicare Coverage for ESRD Dialysis Treatments
Medicare coverage for dialysis must meet certain requirements to start the first month of regular dialysis treatment.
During the first 3 months of dialysis, patients must participate in an at-home training program. After completing the training, Medicare starts the first month that you start regular dialysis treatment.
Some individuals may have the option of finishing dialysis training at-home. Your doctor can approve you to do treatments in your home.
In this case, the dialysis facility must provide you with monthly visits from your doctor. The facility must also provide all the equipment.
Medicare doesn’t cover any procedures or services that involve prepping you for dialysis unless a doctor prescribes it medically necessary.
Tip: Transportation services to and from the dialysis facility for patients with ESRD may be available depending on your plan.
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.
Medicare Dialysis Reimbursement
If you get dialysis at a Medicare treatment center, Medicare reimburses the center for 80%. You pay the other 20% unless you have extra insurance.
Further, Telehealth can help patients get care from home. Patients could have access to consultations, personal check-ins, monthly assessments and more from the comfort of home.
Plus, the facility can get reimbursements for these services.
Identifying and Treating At-Risk People Sooner
An executive order will select a payment model that tests innovations in compensations for kidney care providers. The 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. Also, 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.
Common Questions About Medicare and ESRD
I Just Started Dialysis, How Do I Get Medicare?
You can apply for Medicare by visiting your local Social Security office.
If you get dialysis at a treatment center, Medicare benefits take effect at the beginning of the fourth month after your treatment starts.
For example, if you start dialysis in March, your Medicare coverage will begin on June 1st.
But, if you enter a training program to learn to perform dialysis at home, your benefits can begin as early as the first month of dialysis.
Your coverage continues for 12 months after your last dialysis treatment.
End-Stage Renal Disease Medicare Application Form
If you are under 65, you can apply for Medicare by visiting your local Social Security office or calling the phone number.
Those 65 or older, may apply online.
Can you enroll in Medicare Advantage with ESRD?
You cannot enroll in Medicare Advantage if you have ESRD. You can have a Medicare Advantage Special Needs program that covers ESRD.
If you have had a successful kidney transplant, you may once again be eligible for Medicare Advantage.
How much does Medicare pay for dialysis?
Part B pays 80% of the Medicare rate for dialysis. Medicare covers equipment, injectable drugs, intravenous drugs, laboratory testing, and training for home dialysis.
Part D covers dialysis medications that are only available in oral form. Coverage and costs can vary depending on your prescription drug plan.
Why is end-stage renal disease covered by Medicare?
Congress approved Medicare coverage for ESRD in 1972 as part of an amendment. ESRD is one of only two medical conditions that immediately qualify patients for Medicare before age 65.
The other is ALS or Lou Gehrig’s Disease. At the time of amendment approval, kidney patients were dying because they couldn’t afford dialysis.
Kidney disease advocates made a compelling case that ERSD patients needed special treatment.
Can I Get a Medicare Supplement if I have End-Stage Renal Disease?
Even with Medicare, people with ERSD face high out-of-pocket costs. Medicare Supplement policies can help, but only some states sell them to people under 65. The monthly premiums are usually much higher than they would be if you were 65 or over.
Once you turn 65, you have a six-month Medigap Open Enrollment Period. You can enroll in Medigap without answering health questions.
Get Help Finding Your Policy Match Today!
It can be tough to find Medicare coverage for ESRD patients. Depending on where you live and your enrollment periods, finding a good policy on your own can be a challenge.
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