Medicare and Chronic Kidney Disease

Medicare is a federally funded health insurance program for Americans over age 65 and people who have been deemed disabled. In 1972, people requiring dialysis became newly entitled to this health benefit. The law was amended in order to provide coverage to people who may have forgone treatment due to the high costs of dialysis treatment. Today, if you have chronic kidney disease (CKD) and need dialysis, you may be eligible for Medicare insurance.


Medicare overview

Medicare is health insurance for people who fit one of the following 3 categories:

  • Age – 65 or older
  • Disability – 100% disabled (deemed by Social Security Administration for 2 years)
  • ESRD – any age person with end stage renal disease (ESRD)

Medicare has the following parts:

  • Part A (Hospital Insurance) – Covers all inpatient services
  • Part B (Medical Insurance) – Covers all clinical outpatient services
  • Part C (Medicare Advantage Plans) – Such as HMO or PPO
  • Part D (Medicare prescription drug coverage) – Offered to anyone with Medicare

Medicare drug plans are run by insurance companies and other private companies approved by Medicare.

Age – If you get benefits from Social Security or the Railroad Retirement Board, you are automatically entitled to Medicare Part A and Part B starting the first day of the month you turn age 65.Your Medicare card will be mailed to you about 3 months before you turn 65. However if you’re still actively working you may not be required to obtain Medicare due to age.

Disability – If you are under age 65 and disabled, and have been entitled to disability benefits under Social Security or the Railroad Retirement Board for 24 months, you are automatically allowed Medicare Part A and Part B on month 25 of disability benefit privilege. You will not need to do anything to enroll in Medicare. Your Medicare card will be mailed to you about 3 months before your Medicare entitlement date.

ESRD – If you have end stage renal disease requiring dialysis at any age, you may be entitled to Medicare health benefits called Original Medicare. After you enroll for Medicare health benefits, your effective date of coverage will be determined based on your type of treatment.

Patients with ESRD who begin home dialysis (peritoneal dialysis or home hemodialysis) have an additional advantage regarding Medicare coverage. If you choose a home dialysis therapy you can qualify for Medicare immediately upon the initiation of dialysis.

Common questions kidney patients have about Medicare

How do I enroll in Medicare when I have ESRD?

The Social Security Administration handles Medicare eligibility and enrollment. If you have end stage renal disease and want to enroll in Medicare, go to your local Social Security office or call 1-800-772-1213.

What does Medicare pay for when I have ESRD?

Medicare covers certain medical services and supplies in hospitals, doctors’ offices and other health care settings. When you need dialysis, Medicare covers the cost of dialysis treatments, such as in-center hemodialysis, in-center nocturnal hemodialysis, home hemodialysis (HHD) and peritoneal dialysis (PD). Many people on dialysis are covered under Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). If you have both Part A and Part B, these services and supplies must be covered as long as they are reasonable and necessary for your health, no matter what type of Medicare plan you have. Dialysis patients need to go to a treatment facility where dialysis is covered by Medicare.

Table 1 shows what Medicare pays for when you require dialysis.

Table 1.

Service or supply

Medicare Part A

Medicare Part B

Inpatient (hospital admittance) dialysis treatments

Yes

 

Outpatient dialysis treatments (at a dialysis center)

 

Yes

Home dialysis training (covers training for both the patient and their care partner)

 

Yes

Home dialysis equipment and supplies (home dialysis machine, wipes, gloves, etc.)

 

Yes

Home dialysis support services (visits from home dialysis training nurse, emergencies with equipment, etc.)

 

Yes

Some home dialysis medicine (such as heparin, Epogen, etc.)

 

Yes

Outpatient doctors’ visits

 

Yes

Other services and supplies required for dialysis (such as laboratory tests and dietitian and social worker assistance at the dialysis center)

 

Yes

Medicare does not provide coverage for a paid individual to act as a care partner if you do home dialysis, payment for a person to help during training for home dialysis or transportation to and from the dialysis center. Medicare also doesn’t cover a place to stay during treatment if you live far from a dialysis center, and does not cover blood or packed red blood cells for home hemodialysis (unless advised differently by your doctor, or it’s needed to prime the dialysis machine).

What do kidney patients pay for when they receive Medicare?

Patients pay 20% coinsurance, also called cost share, for dialysis treatment in a dialysis center. Coinsurance is a part in medical insurance that says the person insured pays a certain amount of money for medical treatment or fixed rate on a prescription. Outpatient doctors’ visits will also cost 20% coinsurance. The same amount also relates to home dialysis training, home dialysis equipment and supplies. All of these are applicable if you have Medicare Part B. If you are admitted to a hospital for dialysis, your Part A insurance will cover those costs.

I want a kidney transplant – does Medicare cover this?

Yes, Medicare covers kidney transplants as long as the surgery is performed at a Medicare-approved hospital. When you have Part A insurance, it covers your hospital stay, full care of the living kidney donor, lab work and other hospital services. Part B covers doctors’ services for you and the living kidney donor, blood work and immunosuppressive drugs (medicine used to reduce risk of kidney rejection).

Medicare will cover you for 36 months after the month you receive a kidney transplant. After that time, you will not be covered by Medicare to pay for your immunosuppressive drugs. You may still receive Medicare insurance after your kidney transplant if you meet the following requirements:

  • You had Medicare before being diagnosed with ESRD, because you are over age 65 or disabled.
  • You become eligible for Medicare (turn 65 or disabled) after your kidney transplant.

How does Medicare Coverage differ if I choose peritoneal dialysis (PD) or home hemodialysis (HHD) instead of traditional in-center hemodialysis?

For people who do not already have Medicare coverage and begin hemodialysis, Medicare does not become activated until 90 days after dialysis is initiated.You may be held responsible for costs during this time period if you do not qualify for Medicaid or have some other form of insurance coverage. However, if you chose peritoneal dialysis or home hemodialysis, Medicare can become activated immediately and can retroactively cover services provided even before you start dialysis if they are done in the same month in which you began dialysis. For example, if you start peritoneal dialysis on May 22, Medicare coverage will begin on May 1.  If you were to start in-center hemodialysis on May 22, Medicare coverage would not begin until August 1.

What preventive services does Medicare cover?

Medicare Part B covers certain preventive services, which are listed in the Medicare handbook. The list includes screenings for:

 Also covered by Medicare Part B:

  • diabetes self-management training
  • flu shots
  • glaucoma tests
  • Hepatitis B shots
  • mammograms
  • medical nutrition therapy services
  • pap tests and pelvic exams
  • physical exam (one-time “Welcome to Medicare” physical exam)
  • pneumococcal shot
  • smoking cessation counseling

Do I have to pay for Medicare Part A and Part B?

You will not have to pay for Medicare Part A if you or your spouse worked and paid Medicare taxes for at least 10 years. If you or your spouse did not pay Medicare taxes while you worked and you are age 65 or older, you may be able to buy Part A.

People on dialysis at any age will pay a standard monthly Part B premium, and likely pay for Part A. Some people will pay a higher premium based on their income.

Can I postpone Medicare Part B enrollment without paying higher premiums?

Yes. There are some instances in which you can postpone your Medicare Part B enrollment without having to pay higher premiums. You may have opted not to take Medicare Part B when you were first qualified to do so, because you or your spouse had group health insurance through active employment. When you do decide to enroll in Medicare Part B, you can sign up during a Special Enrollment Period.

When can I expect Medicare premiums and coinsurance rates to change?

Each fall, new Medicare premium and coinsurance rates come out and are effective in January. Every year you receive Social Security premiums or Railroad Retirement benefits, and new rates are mailed to you with your December cost of living adjustment notice.

What is Medigap and can I get this policy if I have ESRD?

Medigap is health insurance that fills in the “gaps” that Original Medicare Plan won’t cover and is sold by private insurance companies. If Medicare can’t pay certain health care costs, Medigap can usually pay for what was not covered.

Please note that not all private insurers will sell Medigap to people under age 65, even if they have end stage renal disease. Medigap rules vary from state to state, and if you are under 65 and receive this policy, you may pay more because of your age.

Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. In addition, you will have to pay a premium to the Medigap insurance company.

Summary

When you discover you have end stage renal disease, you will want to know what your options are in regards to health coverage. Medicare is a government health insurance that covers Americans in need of dialysis, even if you are under age 65. Once you decide which policy works best for you, you can know that you are covered.

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