Will Medicare Cover My Chronic Kidney Disease?

Kidney disease is a leading cause of death in the United States. It affects approximately 37 million people –
more than one in seven adults. The great majority (90%) have no idea that they even have it.¹ 

Chronic kidney disease is defined as damage that has been done for three or more months. It means your kidneys are having trouble filtering blood as normal, causing wastes to build up in your body as well as other health issues.

If you’re wondering how to use Medicare benefits to help manage your kidney disease-related costs, you’re not alone. We’ll break down the various parts to better help you make the right choices for your individual situation.

Original Medicare and Chronic Kidney Disease Care

Original Medicare coverage for chronic kidney disease care depends on which stage of the disease you’re living with. For example, Medicare covers up to 6 sessions of kidney disease education services if you have Stage IV chronic kidney disease and your health care provider refers you for the service. 

The fifth and last stage is end-stage renal disease (ESRD) which qualifies you for even more specialized services.
To learn more about Medicare coverage for ESRD, click here.

Part A
Medicare Part A (hospital care) covers hospital stays and skilled nursing facilities. Coverage for chronic kidney disease often includes:

• Inpatient dialysis treatments 
• Kidney transplants 
• Other inpatient care 
• Skilled nursing facility care 
• Home health care 
• Hospice care 

You’ll be subjected to the Part A deductible ($1,556 in 2022) as well as other potential out-of-pocket costs.

Part B
Medicare Part B (medical care) covers medically necessary and preventative services stemming from chronic kidney disease. These include:

• Outpatient dialysis 
• Home dialysis (training, supplies, equipment, support services) 
• Outpatient medical visits 
• Clinical research 
• Ambulance services

You’ll be subject to the Part B deductible ($233 in 2022) as well as other potential out-of-pocket costs. 

Living with more than one chronic condition?
You may qualify for Chronic Care Management under Part B if you have chronic kidney disease plus one or more other chronic conditions. Some of the most common include asthma, arthritis and diabetes.

Part B Chronic Care Management services include:

• Around-the-clock provider access 
• At least 20 minutes of related services monthly 
• An individually crafted care plan 
• Regular check-ins with your doctor or provider

Providers who can bill for this include:

• Physician assistants 
• Nurse specialists 
• Midwives 
• Nurse practitioners 

Those who cannot bill for Chronic Care Management include: 

• Dentists 
• Podiatrists 
• Psychologists 
• Limited-license doctors 

Medicare Advantage and Chronic Kidney Disease Care

Medicare Advantage offers privately sold plans that have all the benefits you’ll find in Original Medicare (Parts A and B) but also include extended benefits such as vision, dental, prescriptions and wellness programs.  

Many Advantage plans (also known as Part C) have provider networks with preselected doctors and other medical personnel, so if you already have a preferred physician, it’s best to make sure that they are in-network.

Also, part of Medicare Advantage’s offerings are Chronic Condition Special Needs Plans (C-SNP), which are designed to serve those living with specific diseases such as chronic kidney disease. Some say you must stay
in-network for your providers, while others will allow you to go out of network. You’ll have to choose a primary care doctor and will need a referral for most specialist services, but some (including pap tests and annual screening mammograms) can be accessed without a referral. 

Care coordinators are one of the most notable benefits of a C-SNP. Their job is to help you stay current with your care needs. This may mean getting the right medications, scheduling appointments or monitoring other
health-related activities. 

Prescription Coverage for Kidney Diseases Through Part D

Part D (prescription drug coverage) is not included in Original Medicare and must be purchased separately. Approximately 71% of chronic kidney disease patients are enrolled in Part D, which is slightly higher than the general Medicare population (66%) but lower than those with end-stage renal disease (77%).² Part D covers kidney drugs including:

• Statins 
• Insulins 
• Beta blockers 
• Opiate agonists 
• Loop diuretics 
• Proton-pump inhibitors 
• Angiotensin-converting enzyme 

Since formularies vary between Part D plans, it’s a good idea to make sure that your individual medications are on your preferred plan before choosing that coverage.

Medicare Supplement Insurance and Chronic Kidney Disease Care

Also known as Medigap, Medicare Supplement Insurance is responsible for filling in the gaps in coverage between Original Medicare and your healthcare costs. Notably, it covers the 20% not covered by Medicare Part B for outpatient services such as dialysis as well as immunosuppressant medication for transplant recipients.  

However, Medigap does not typically cover:

• Eyeglasses 
• Hearing aids 
• Vision care 
• Dental care 
• Long-term care 
• Private-duty nursing 

If you’re applying outside your Medigap Open Enrollment Period, you will be subject to underwriting that could result in getting denied coverage. That’s because certain chronic conditions, including kidney failure, can be automatic reasons for denial. That said, underwriting guidelines do vary, so you’re not automatically ineligible for Medigap.

What are the Risk Factors for Chronic Kidney Disease?

Chronic kidney disease is often asymptomatic, making it even more important to understand your risk factors. These include:

• Diabetes, given that high blood glucose can damage blood vessels in the kidneys. 
• Heart disease, a link that researchers are currently trying to better understand. 
• High blood pressure, since nearly 1 in 5 adults with this also have chronic kidney diseaseⁱⁱⁱ. 
• Family history, since chronic kidney disease is hereditary. 

If you have one or a combination of these risk factors, you should consult your preferred physician to assess your kidney health.

Conclusion

Living with chronic kidney disease can be scary. Especially when there’s the possibility of your kidney issues progressing into end-stage renal disease. Prioritizing your health can help manage this risk.  

While making healthy food choices and increasing your physical activity may seem like obvious solutions, a less obvious one is ensuring you have health coverage that can handle your needs. That includes providing services to help manage diabetes, high blood pressure, heart disease and other conditions that could worsen your kidney health.  

If you’re unsure of which Medicare solutions will provide the services you need most, we can help. Give us a call to speak with a licensed agent specializing in Medicare plans in your area.