If you have End-Stage Renal Disease (ESRD), you may wonder what your healthcare options are, especially when it comes to Medicare. It’s our job to make Medicare easy. Here’s what you need to know.
Automatic Medicare Enrollment with ESRD
Generally, Medicare enrollment eligibility begins three months before the month you turn 65. Individuals receiving disability insurance may enroll early, although Medicare requires a 24-month delay after recipients begin receiving disability benefits. That’s not the case if you have ESRD, as eligibility as a result of disability can happen at any age. Unlike other disabilities, if you have ESRD, Original Medicare (Parts A and B) coverage begins after your fourth month of dialysis treatment. Coverage may begin after your first month of treatment if you meet these eligibility requirements:
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You participate in a Medicare-approved program that teaches you how to perform self-dialysis at home during the first three months of treatment
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Your doctor expects you to be able to do your own dialysis treatments
If you have ESRD, you should receive a Medicare card in the mail when your coverage starts. This card is red, white and blue and states your Medicare Number. You will need this number if you choose to enroll in a Medicare Advantage, Medicare Supplement Insurance (Medigap), or Prescription Drug plan.
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Original Medicare ESRD Coverage
Medicare Parts A and B, also known as Original Medicare, can offer coverage for select services and equipment. You are responsible for the 20 percent Medicare coinsurance for all Medicare-covered services.
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(hospital care) will cover necessary treatment that occurs at an inpatient facility, like a hospital. For example, Part A will cover kidney transplant surgery or dialysis treatment in the hospital.
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(medical care) will cover specific prescription drugs related to a kidney transplant or dialysis. Part B will also cover dialysis in an outpatient facility or at home.
If you are under 65 and you have stopped dialysis treatments for 12 months or are 36 months post-op from a kidney transplant, your Original Medicare coverage will end. It will start again if you resume dialysis or have another kidney transplant.
Original Medicare doesn’t include coverage for prescription drugs outside of those related to ESRD transplants or dialysis. If you need or want coverage for other medications, you will need to enroll in a Medicare Part D prescription drug plan. You can enroll in a standalone Part D plan, or choose a bundled plan that includes coverage for Part A, Part B, and Part D. These plans are known as Medicare Advantage Prescription Drug plans (Part C).
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Additional benefits through Medicare Advantage
If you have ESRD, you may find that you are looking for more coverage or benefits than Original Medicare can provide. Medicare Advantage plans are offered by private insurance companies and include all of the same coverage as Original Medicare as well as additional benefits in a single plan. Often, Medicare Advantage plans offer low-to-no cost premiums, deductibles and copay/coinsurance. You are still responsible for your Part B premium. Examples of additional coverage include:
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Vision
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Dental
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Hearing
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Prescription Drugs
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Home Health Care Services
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Fitness
Medicare Advantage plans – offered by private insurance companies – include your Original Medicare coverage and may include many of these additional benefits in a single convenient plan. If you have ALS, you may find a Medicare Advantage plan to be more cost effective than Original Medicare. Many Medicare Advantage plans offer low-to-no premiums, deductibles and copays/coinsurance. Additionally, because Medicare Advantage plans often include Part D prescription drug coverage, obtaining your medication may be more financially friendly and convenient.
ESRD Special Needs Plan
Medicare Chronic Special Needs Plans (C-SNP) are a type of Medicare Advantage plan that offer coverage and benefits specific to certain conditions, such as End-Stage Renal Disease. This means that these plans may offer access to specialists and cover common prescriptions used by individuals with ESRD.
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Frequently Asked Questions
Also known as end-stage kidney disease or kidney failure, ESRD is when your kidneys are in permanent failure, to the point where you need regular dialysis or a transplant.
Enrollment Eligibility
Annual Enrollment Period (AEP)
Medicare Annual Enrollment Period runs each year from October 15 to December 7. What is the Annual Enrollment Period vs. Open Enrollment Period?
Initial Enrollment Period (IEP)
Your Initial Enrollment Period generally surrounds your 65th birthday but may occur if you otherwise become eligible for Medicare for the first time.
Special Enrollment Period (SEP)
You may be eligible if you experience a qualifying life event such as moving to a new zip code, losing employer coverage, or change in Medicaid status.
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Further Reading:
What is Medicare Part D? | Prescription Drug Plans
Medicare through Social Security Disability Insurance
