Will Medicare Cover My End-Stage Renal Disease?
End-Stage Renal Disease occurs when your kidneys stop functioning permanently, resulting in the need for dialysis or a kidney transplant. If you develop ESRD, you may automatically become entitled to Medicare benefits.
We’ll break down the various elements so that you can chart your own enrollment course.
ESRD and Medicare Coverage Start Dates
If you enroll in Medicare early due to ESRD (as opposed to enrolling in Medicare when you become eligible after turning 65) your coverage start date may vary.
When you first enroll in Medicare based on ESRD, your coverage will begin on the fourth month of outpatient dialysis. However, it can start as early as the first month of dialysis if you’re training to do home dialysis.
It can also start the month you are admitted to a Medicare-approved hospital for a kidney transplant or related healthcare services prior to the procedure if it takes place in the same month or within the two following months.
For example, if you have a kidney transplant on April 15, your Medicare entitlement date would be May 1.
If your transplant is delayed for more than two months after you’re admitted to the hospital for the procedure or for healthcare services needed prior to the transplant, your Medicare coverage can start two months before the month of the transplant.
For example, if you were scheduled for pre-surgical health services on October 17 and the transplant was performed on December 5, your eligibility date would be November 1.
If you have Medicare only because of ESRD, the coverage concludes either 12 months after the month you stop dialysis or 36 months after the month you have a kidney transplant.
Now let’s look at how the various parts of Medicare can come together to help you cover your healthcare costs.
Original Medicare and End-Stage Renal Disease Care
Part A (hospital care) covers hospital stays and skilled nursing facilities. Coverage for end stage renal disease often includes:
- Kidney transplants and other surgical procedures
- Hospital inpatient dialysis
- Full cost of care for a kidney donor
- Kidney registry cost
- Limited skilled nursing facility stays
- Short-term nursing home care
- Limited home healthcare
- Hospice care
You’ll be subject to the Part A deductible ($1,556 in 2022) as well as other potential out-of-pocket costs.
Part B (medical care) covers medically necessary and preventative services stemming from end stage renal disease. These include:
- Outpatient dialysis from a Medicare-certified hospital or free-standing dialysis facility
- Home dialysis training from a dialysis facility, including:
- Training for a beneficiary and caregivers who will perform home dialysis
- Home dialysis equipment and supplies
- Treatment-related medications when supervised by a doctor
- Physician fees for kidney transplants
- Physician fees for your donor while they are still in the hospital
- Emergency room visits
- Most vaccinations, including flu shots
- Medications (oral or injectable) required for dialysis
- Durable medical equipment
- Most screenings and diagnostic tests, including kidney function tests
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 ESRD plus one or more other chronic conditions. Some of the most common include asthma, arthritis and diabetes.
Part B Chronic Care Management services include:
- 24-hour provider access
- At least 20 minutes of related services on monthly basis
- An individually crafted plan of care
- Regular check-ins with your doctor or provider
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Providers who can bill for this include:
- Physician assistants
- Nurse specialists
- Nurse practitioners
Those who cannot bill for Chronic Care Management include:
- Limited-license doctors
Medicare Advantage and End Stage Renal Disease Care
These privately sold plans, also known as Part C, offer all the benefits of Original Medicare (Parts A and B) but with a few extras, typically dental, vision, prescription drugs and wellness programs. Part C plans are designed with provider networks, so if you already have a preferred doctor or provider, make sure they’re in-network before selecting one of these plans.
Beginning in 2021, all people living with ESRD are eligible to enroll in Medicare Advantage.i When you’re considering enrolling, it’s helpful to consider how much you will owe for necessary services such as immunosuppressants and dialysis. If you have high costs, Medicare Advantage’s maximum out-of-pocket limits ($7,550 in 2022) can prove very useful.
Chronic Condition Special Needs Plans are another feature of Medicare Advantage. C-SNPs are tailored to those living with specific diseases such as ESRD. While some mandate that you stay within the provider network,
others 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, though some may be accessed without a referral.
One of the hallmark benefits of a C-SNP is the presence of a care coordinator, who is responsible for helping you stay current with your care needs. This may mean scheduling appointments, getting the right medications or monitoring other health-related activities.
Prescription Coverage for ESRD Through Part D
Part D (prescription drug coverage) is not included in Original Medicare and must be purchased separately.
Part D covers kidney drugs including:
- Immunosuppressive drugs for transplant patients
- Infusion drugs such as an IV push
- Injectable drugs
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 ESRD Care
Medicare Supplement Insurance, also known as Medigap, fills in the gaps in coverage between Original Medicare and your healthcare expenses. In particular, 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:
- Hearing aids
- Vision care
- Dental care
- Long-term care
- Private-duty nursing
What are the Risk Factors for ESRD?
Diabetes is the biggest risk factor for kidney disease and the most common cause of kidney failure or ESRD.
There are many other risk factors to keep in mind, though.
Risk factors for ESRD include:
- Heart disease
- High blood pressure
- Urinary tract blockages
- Drug abuse
- Family history
- Some genetic disorders
If you think that you may be at risk for ESRD, talk to your doctor.
Regardless of your age, you may be qualified to receive Medicare benefits that can help you defray ESRD-related costs. However, your employment status and other life factors may determine whether it makes sense for you to enroll in Medicare early (before 65) to receive ESRD benefits.
In any case, receiving care immediately after a diagnosis can be lifesaving. If you need help making fast and trusted decisions regarding which Medicare solutions are right for you, then we can help.
If you have any questions, give us a call to speak with a licensed agent specializing in Medicare plans in your area.
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Denise Austin, 65, Ensurem Ambassador
Best-Selling Author, Creator of Fit Over 50 Magazine
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