Medicare is a federal health insurance program that you pay into throughout your working career. It’s for people who are at least 65 years old or those who are under 65 years old and have a disability.
It’s also for people who have permanent kidney failure, or End-Stage Renal Disease, and need dialysis or a transplant.
Medicare Coverage
Medicare Part A is your Hospital Insurance. Part A helps cover the cost of any inpatient care while in a hospital. Also, inpatient care in nursing facilities (this does NOT include long-term care at these facilities).
There is also coverage for Hospice care and at-home health care, when medically necessary. Most of the time no monthly premium is required for Part A.
To qualify for Medicare Part A, you or your spouse has had to pay Medicare taxes while they worked for at least 40 quarters. Those that work less than 40 quarters have to pay some or all the Part A premium. The Part A premium for 2019 is $437.
Medicare Part B is your Medical Insurance. Part B coverage includes doctor visits and services from your health care provider and any outpatient services or care. Part B covers some at home health care services. Also, preventative services such as test and blood work have coverage.
The Part B premium is $135.50 for 2019. Usually, there is a 20% co-payment that beneficiaries must pay for services and supplies.
Certain medications have coverage under your Part B plan. Therefore, you pay 20% of the cost – as you would any other service under this plan. If you have a Medicare Supplement Plan, that 20% won’t apply to you.
Medicare Part D is what helps pay for prescription drugs. Income determines Part D premiums. If income is low, you may qualify for additional help paying for your Part D prescription drug costs.
After having a kidney transplant, you must take drugs for the rest of your life. The drugs are transplant or immunosuppressive drugs. POST kidney transplant, these drugs reduce the chance of your body rejecting the new kidney.
Medicare Coverage for Kidney Disease
There are multiple options for Kidney Disease and Medicare coverage. Your condition and state of health are what determines the best plan for you.
Medicare will help pay for kidney dialysis and kidney transplants through Original Medicare. However, if you have ESRD (End-Stage Renal Disease) you typically won’t be able to enroll in a Medicare Advantage Plan.
If you do have ESRD, you’ll receive your benefits through Original Medicare. You’ll also be able to go to any doctor that is enrolled and accepts Medicare – they must also be accepting new Medicare patients.
You’ll have coverage at any hospital or facility that participates with Medicare. With Medicare, you should add Part D to your coverage by joining a Prescription Drug Plan.
Medicare Advantage Plans
As mentioned above, you typically can’t join a Medicare Advantage Plan if you already have ESRD prior to enrollment. If you have ESRD, a Medicare Special Needs Plan may be an alternative option if they’re available in your area.
SNP Medicare Advantage Plans are for those that have serious illness or disease, require institutionalization or beneficiaries with Medicaid.
Medicare Eligibility
Age is not a determining factor for eligibility of Medicare when your kidneys aren’t working any longer. Should your kidneys fail, it would be medically necessary and vital that you receive dialysis on a regular basis.
If one of the following statements or questions applies to you, you should file an application today. There may be waiting periods that apply so don’t procrastinate.
- If you need regular dialysis
- You’ve had a kidney transplant
- You contribute to Social Security or the Railroad Retirement Board
- Work the time requirement as a government employee
- Receive benefits or are eligible for benefits for Social Security or RRB
- If you are the spouse or a dependent child of someone who meets any of these requirements
If you qualify for Part A you also qualify for Part B; however, enrolling in Part B is optional.
Once in Medicare Part B, beneficiaries pay a monthly premium for that coverage. To receive all the benefits Medicare will cover for certain dialysis and kidney transplant services, you must have both Medicare Part A and Part B.
If you don’t meet the requirements to qualify for Medicare coverage, your state has options that might help pay for your dialysis treatments. Contact Social Security for further information regarding extra help.
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 a regular course of dialysis – you must participate in an at-home training program by Medicare.
This program when medically necessary should have coverage under Medicare Part B.
Medicare does NOT cover any surgical procedures or services needed to prep you for dialysis if you should need it; procedures such as fistula.
Only after completing the at-home dialysis training will your Medicare coverage kick in the month you begin regular dialysis. Surgical procedures could have coverage once regular dialysis begins.
Medicare WILL cover a fistula placement or other pre-dialysis services if your doctor prescribes it as medically necessary
Medicare Advantage Plans, like HMO or PPO, often will cover services to and from your dialysis facility for people with ESRD (you will need to check your specific plan to see if transportation is covered).
Your dialysis facility is responsible to provide you with monthly visits from your doctor as well as all the equipment medically necessary for at-home treatments.
Dialysis Cost in a Facility
For those who have Original Medicare, you’ll still pay the 20% coinsurance of the amount that has been approved by Medicare for all services you may need – Medicare pays the other 80%.
Medicare Supplement Insurance (Medigap) may cover all or just some of the 20% coinsurance. Costs may be different it’s important to make sure you understand your plan and what you are paying for.
Kidney Transplants
Coverage can start the first month you go to the hospital for a kidney transplant providing it’s a Medicare network hospital. Your transplant must happen within the month you’re admitted or 2 months after being admitted in order to be covered by Medicare.
Medicare covers the deductible, coinsurance, and any other costs for your kidney donor’s stay at the hospital – neither you nor your donor will be responsible for those costs.
Medicare Part B covers these transplant drugs if certain requirements are met, such as:
- Eligible for Medicare due to End-Stage Renal Disease (and you’re not 65+ or are disabled)
- At the time of the transplant, you were already a Medicare Part A beneficiary
- The transplant surgery must have been performed at a facility that accepts Medicare
- You must have Medicare Part B, they won’t cover anything prior to enrollment
Say you’re only eligible for Medicare because you have permanent kidney failure, your Medicare coverage for transplant drugs will stop after 36 months from the month of your kidney transplant.
Other options are available to help you pay for these drugs, talk to your healthcare provider for more information. However, Part B does not cover most prescription drugs; Medicare Part D helps pay the costs of prescriptions.
Medicare Continues to pay for transplant drugs when you’re:
- Previously eligible for Medicare due to age or a disability BEFORE you were diagnosed with ESRD
- Eligible for Medicare due to age or disability AFTER getting a kidney transplant that Medicare paid for
- If private insurance paid the primary to your Medicare Part A coverage
All services must have been at a facility that accepts Medicare.
Medicare Coverage for Kidney Disease Education
You are covered for up to 6 sessions of kidney disease education if you have stage 5 kidney disease – typically needing dialysis or a kidney transplant.
These education sessions are important for learning how to cope with your kidney disease, manage life and finances, how to stay as healthy as possible, what you can expect through treatment, and give you an outlet to discuss how you feel. Mental health is just as important as physical health.
Be sure to always consult with your Medicare professional agents to ensure you’re getting the best coverage possible.