Many people assume that Medicare is just for individuals over the age of 65, but people of any age with End-Stage Renal Disease, permanent kidney failure requiring dialysis or a kidney transplant, are also eligible for Medicare benefits. You may have specific coverage needs and limited plan options, so let’s discuss ESRD and how insurance can help you get the care you need at a price you can afford.
What is end-stage renal disease?
The Mayo Clinic defines ESRD as advanced kidney disease that occurs when the kidneys stop functioning on a permanent basis and you need dialysis or a kidney transplant to maintain life. While some people may be at a higher risk for ESRD, including seniors, males, people of African American descent, and tobacco users, anyone with kidney disease may face a progression to ESRD. If you or a loved one experience any of the following symptoms, talk to your doctor immediately:
· Loss of appetite
· Fatigue and weakness
· Swelling of feet and ankles
· Changes in urination
· Muscle cramps
· Shortness of breath
· Chest pain
· High blood pressure
· Persistent itching
If you are diagnosed with ESRD, you may be eligible for Medicare benefits, regardless of age.
When do you qualify for Medicare due to ESRD?
According to the Centers for Medicare & Medicaid Services, Medicare coverage based on ESRD usually starts:
- On the fourth month of dialysis when a beneficiary participates in dialysis treatment in a dialysis facility.
- As early as the first month of dialysis if the beneficiary takes part in a home dialysis training program in a Medicare-approved training facility, begins home dialysis before the third month of dialysis, and the beneficiary expects to finish home dialysis training and administer self-dialysis treatments.
- The month the beneficiary is admitted to a Medicare-approved hospital for kidney transplant or for health care services that are needed before the transplant if the transplant takes place in the same month or within the two following months.
- Two months before the month of the transplant if the transplant is delayed more than two months after the beneficiary is admitted to the hospital for that transplant or for health care services that are needed before the transplant.
What type of Medicare plan can you enroll in?
Most people with ESRD will get their insurance coverage through Original Medicare. You will be able to visit any Medicare-approved doctor or supplier, and will be responsible for paying a deductible and co-insurance or copayments for covered services and supplies. You may want to consider enrolling in a stand-alone Prescription Drug Plan (PDP) to have coverage for prescription medications you may need. If you become eligible for Medicare based on ESRD, you will have a 7-month Medicare drug plan enrollment period that begins 3 months before the month you are eligible, and ends 3 months after the month you are eligible.
If you already have ESRD and haven’t had a kidney transplant, you may not be eligible to enroll in a Medicare Advantage plan if you are not already enrolled in one prior to your diagnosis, but you may be able to join a Medicare Advantage Special Needs Plan (SNP) if one if available in your area. A SNP will cover all of your Part A and Part B benefits.
If you had ESRD, had a successful kidney transplant, and still qualify for Medicare based on age or disability, you can stay in Original Medicare or join a Medicare Advantage plan.
What kidney transplant services will be covered by Medicare?
Medicare Part A will help cover the costs of:
· Inpatient services in a Medicare-certified hospital
· Kidney registry fee
· Lab tests to evaluate your condition and the condition of potential kidney donors
· Finding the proper kidney for transplant surgery
· Pre-op, surgery, and post-op care for the kidney donor
· Any additional inpatient hospital care for kidney donor
Medicare Part B will help cover the costs of:
· Doctors’ services for kidney transplant surgery
· Doctors’ services for the kidney donor during their hospital stay
· Immunosuppressive drugs for a limited time after the transplant (as long as you are enrolled in Part A and Part B and your transplant took place at a Medicare-approved facility)
When will Medicare coverage end after a transplant? If you are eligible for Medicare only because of permanent kidney failure, your coverage ends 36 months after the kidney transplant. Medicare will continue to pay for transplant drugs with no time limit if you were already eligible for Medicare before your diagnosis of ESRD or have reached eligibility since.