Medicare and ESRD

Medicare helps to pay for kidney dialysis as well as kidney transplants.

Eligibility

• A person whose kidneys no longer work can get Medicare no matter what their age as long as they meet other criteria.
• You have worked long enough to qualify for retirement benefits from Social Security, the Railroad Retirement Board, or as a government employee
• You are already receiving retirement benefits
• You are the spouse or child or a person who meets either of the above criteria

In order to receive full benefits you must apply for both Medicare Part A and B and wait the required amount of time. If you don't qualify for Medicare, you may be able to get help from your state to pay for your dialysis treatments.

A person with ESRD who is new to Medicare will most likely be covered under “original Medicare” rather than a Medicare Advantage Plan. A Medicare Part D plan may also be selected to help cover prescription costs. Some people may be able to enroll in a Medicare Special Needs Plan if there is one in their state.

Children and Medicare
A child with permanent kidney failure is eligible for Medicare as long as one with their parents has worked long enough to qualify for retirement benefits through Social Security, the Railroad Retirement Board, or as a government employee. A child can also be eligible if they are already receiving benefits from Social Security or Railroad Retirement.

When does Coverage Start?

When enrolling in Medicare because of ESRD and on dialysis, Medicare coverage usually starts the first day of the fourth month of dialysis treatments.

If a person is covered by a group health plan related to employment, this plan will pay first for 30 months of dialysis treatments and Medicare pays second. If there is no group health plan there are other programs that can bridge the gap and help pay expenses not covered by Medicare.

This 30 month window is called the coordination period, and it starts whether or not a person has applied for Medicare coverage. When an approved Medicare home training program is completed or a transplant is done during the initial 3 month waiting period, the coordination period will start earlier.

If the group health plan has deductibles or co-insurance, Medicare A and B may help to pay for these expenses. Since Part B has a premium some people may find it better to wait to enroll until the 30 month coordination period is over to avoid paying premiums that may not be needed. If the group coverage ends before the coordination period has passed it will be important to sign up for Medicare Part A and B right away.

What happens after the coordination period?

At the end of the 30 month coordination period, Medicare begins to pay first for all covered services. Usually the group health plan coverage pays for services not covered by Medicare. Plans can vary so it is wise to check with the benefit coordinator for the group health plan to verify coverage.

Special Circumstances

There is a separate 30-month coordination period each time a person enrolls in Medicare because of permanent kidney failure. When a kidney transplant continues to work for 36 months, Medicare coverage ends unless a person is over 65 or disabled for another reason. If the transplant then fails a person will need to re-enroll in Medicare but coverage will begin right away, without the 3 month waiting period. There will be a new 30 month coordination period if there is a group health plan providing coverage.

Coverage Exceptions

• Medicare can become effective sooner if a person meets both of these criteria
• When a person takes part in a Medicare approved home dialysis training program
• Your doctor expects the person to finish training and be able to do their own dialysis treatments at home

Medicare coverage can begin the month a person is admitted to a Medicare-approved hospital for a kidney transplant (or services that are needed before a transplant) as long as the transplant takes place in that same month or within the following 2 months.

Medicare does not pay for care that is needed in order to prepare for dialysis such as fistula placement unless the person has completed an approved home training program and starting regular dialysis all in the same month.

When does coverage end?

If eligibility for Medicare is only because of permanent kidney failure, coverage ends when:

• It has been 12 months since dialysis was stopped
• 36 months after a kidney transplant

Medicare coverage may be extended if one of the following criteria is met:

• Dialysis is restarted or a transplant is done within the 12 months after dialysis was stopped
• If dialysis is restarted or another kidney transplant is performed within 36 months after the first transplant

References

Q1 Medicare.com: http://www.q1medicare.com/PartD-MoreOnTheDonutHolesOrCoverageGap.php

Medicare website: https://secure.ssa.gov/apps6z/i1020/main.html

Medicare Basics: https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf