Medicare Coverage for End-Stage Renal Disease (ESRD), Dialysis & Kidney Transplants

You can get  premium-free Part A Hospital if you get regular dialysis treatments or need a kidney transplant, have filed an application for Medicare, and meet 1 of the following conditions:

• Have worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee; or
• Are getting or are eligible for Social Security or RRB benefits; or
• Are the spouse or dependent child of a person who has worked the required amount of time under Social Security, the RRB, or as a government employee; or are getting Social Security or RRB benefits.

Part A Hospital coverage begins:

• The 3rd month after the month in which a regular course of dialysis begins;
  • See FAQ for more detail,  or
• The first month a regular course of dialysis begins if the individual engages in self-dialysis training; or
• The month of kidney transplant;
  • FAQ for more detail,
  • Transplant Costs & Insurance -Kidney.org   or
• Two months prior to the month of transplant if the individual was hospitalized during those months in preparation for the transplant. ^{Citations –  (CMS) * Publication 10128 Page 6 *} 
  • FAQ about full recovery after transplant and special enrollment to get new coverage
• Part A & B Enrollment – Sign Up?

Resources & Links

•  time.com  first-pig-kidney-transplant
  • kff health news.org/first-pig-kidney-transplant
• haaretz.com/china-harvested-organs-from-living-people-doctors-helped-with-executions

How much does kidney dialysis cost? 

How is it covered under the various options for Medicare Coverage?

How costly is kidney failure treatment?

Kidney failure treatment—hemodialysis, peritoneal dialysis, and kidney transplantation—is costly, and most people need financial help. The average cost to Medicare per person in 2011 was¹

• almost $88,000 for hemodialysis, a treatment for kidney failure that filters blood outside the body
• more than $71,000 for peritoneal dialysis, a treatment for kidney failure that uses the lining of a person’s abdominal cavity as a filter
• almost $33,000 for a transplant, surgery to place a healthy kidney from someone who has just died or a living donor, usually a family member, into a person’s body ^nih.gov  *

**********

Dialysis is used during end-stage kidney failure to replace the functions of the kidneys — including waste removal and regulation of blood levels of potassium and sodium.

Typical costs:

• Dialysis is covered by health insurance.
• For patients covered by health insurance, out-of-pocket costs typically include the deductible, and coinsurance for the treatment cost.
  • For example, with Medicare, a patient, once the deductible of about $150 is met, typically would pay coinsurance of 20%; but many Medicare patients also have secondary insurance to cover all or part of that cost.
• A study published in Health Affairs^[1] showed that the average U.S. patient pays $114 for dialysis-related drug costs and about $10 in dialysis costs per month.  ^{health.costhelper.com/dialysis.html}   *

• Cost of dialysis
• davita.com/insurance-financial-management

New Rule to promote at-home dialysis services

• kidney.org/home hemo 
• fresenius kidney care.com/home-hemodialysis
• home dialysis.org/home-dialysis-basics
• davita.com/can-anyone-do-dialysis-at-home

and transplant care for people from underserved communities —- decisive step to ensure people with Medicare with chronic kidney disease have easy access to quality care and convenient treatment options 42 CFR Parts 412, 413 and 512  Final Rule  ^{Modern Health Care} *

New rule to promote at-home dialysis services and transplant care for people from underserved communities, which marks the agency’s first effort to tackle health disparities for Medicare enrollees with kidney failure in the decade since Congress established the prospective payment system for ESRD providers. CMS published the proposed rule for ESRD payments in July. ^{.modernhealthcare.com/payment/medicare-drops-changes-esrd-payment-health-equity-mind}

• See our page on what Medi Gap  and Medicare Pay.
• View Typical Summary of Benefits for MAPD
• latimes.com/dialysis-industry-political-spending
• kevin md.com/involuntary-discharge-dialysis
• Dialysis Management Solutions (DMS) provides services to help self-funded employers and brokers manage the impact of dialysis claims and ease the stop-loss renewal process.

FAQ’s

• What about  staying with under an under 65 plan?  Covered CA? 
• Who gets on the list for a kidney?
• Are patients being forced into Medicare – Insurers making Dialysis clinics out of Network?
  • Supreme Court sides with insurer in dialysis coverage case
  • Supreme Court rules in favor of insurance plan that pushed kidney failure patient to Medicare
  • The Supreme Court’s Dialysis Ruling Reinforces Self-funding as the Only Affordable Option
  • Medicare expenditures could be reduced by increased peritoneal dialysis use
  • does-medicare-cover-nutrition-counseling  Medicare.Gov *
  • Helping employers manage all aspects of outpatient dialysis claims by reducing costs and focusing on patient care. 
  • A transplanted pig kidney offers a grandmother hope for life without dialysis  NPR.Org *
    • Medicare is experimenting with how it pays for kidney transplants  Association of Health Care Journalists
    • Tool of genocide’: Chinese government is forcibly removing organs from prisoners’ bodies  USA Today June 2022 
• Covered CA Guaranteed Issue SEP Special Enrollment Period for when you lose Medicare Kidney Coverage  our webpage 

• Medi-Gap policy?
  Can you get or keep one?

  • If you have a Medi Gap plan before you are diagnosed with ESRD, you can keep it.
    • Anthem Blue Cross
    • Blue Shield – Medi-Gap – Any Medicare Provider
    • Health Net Medi Gap
    • UnitedHealthcare  Medi Gap
  • There is also a guaranteed issue opportunity when you turn 65,   ^{Medicare Publication Kidney Dialysis & Transplant Services # 10128.  page 42}.
  • If you get a Medicare Advantage plan, you could then change to Medi Gap under the 1 year free trial rule MAYBE!!!
    • If this is your situation, ask us and we will double check.  One must read the law 3 times and then when you think you understand it, read it again.
    • One could also hope for a “Underwriting Holiday.”
    • Anthem MediBlue Plus & SNP
    • Blue Shield 65 Plus – Inspire HMO 2024
    • Scan
    • SNP Special Needs Plans Medicare Advantage
    • UnitedHealthcare
  • If you are not in a guaranteed issue period, here’s the underwriting questions, so forget it.

You cannot buy additional coverage through #Covered California
if you have premium-free Medicare Part A Hospital

Medicare complies with Health Care Reform, so you do NOT need to get a an Individual policy or a subsidized one from Covered CA.  It fact, it's illegal for anyone to sell you a policy!  ^{Kaiser Health News * Covered CA Medicare Fact Sheet * Medicare.Gov Medicare & Market Place #11694  * CMS.Gov FAQ Medicare & Marketplace * HealthCare.Gov when - how to change from Covered CA to Medicare  * Social Security §1882  * Health Care.Gov}

NOTE: This information also applies to people younger than 65 whose benefits begin the first month they receive disability benefits because they have Amyotrophic Lateral Sclerosis (ALS), better known as Lou Gehrig’s Disease, and to people younger than 65 who have Medicare because of a disability and are receiving SSDI Social Security Disability Insurance.

There are a lot of ands, if or buts in this complex issue.  Please refer to the source material below.  There are some exceptions, but they are very complex.  Don't even think of getting a 1/2 correct answer over the phone. If you have to pay for Part A Hospital, then are options, like subsided Covered CA Plans. Email us [email protected]

Video about Covered CA – if no Premium Free Part A – jump to 2:30  Medicare & the Marketplace (Covered CA

• Medicare Publication # 11694 Medicare & Covered CA
  • Covered CA Medicare Fact Sheet 
  • Medicare vs Covered CA - Publication 11694

    Selling Covered CA  Plans To Medicare Beneficiaries Will Be Illegal  Kff.org 

  • InsureMeKevin.com
  • Publication 02179 How Medicare works with other Insurance  Our webpage 

Sec. 1882. [42 U.S.C. 1395ss]

(3)(A)

(i) It is unlawful for a person to sell or issue to an individual entitled [no premium] to benefits under part A or enrolled under part B of this title (including an individual electing a Medicare+Choice plan [MAPD] under section 1851)—

(I) a health insurance policy with knowledge that the policy duplicates health benefits to which the individual is otherwise entitled under this title or title XIX,

(II) in the case of an individual not electing a Medicare+Choice plan, [aka MAPD Medicare Advantage] a medicare supplemental policy with knowledge that the individual is entitled to benefits under another medicare supplemental policy or in the case of an individual electing a Medicare+Choice plan, a medicare supplemental policy with knowledge that the policy duplicates health benefits to which the individual is otherwise entitled under the Medicare+Choice plan or under another medicare supplemental policy, or

(III) a health insurance policy (other than a medicare supplemental policy) with knowledge that the policy duplicates health benefits to which the individual is otherwise entitled, other than benefits to which the individual is entitled under a requirement of State or Federal law.

(ii) Whoever violates clause (i) shall be fined under title 18, United States Code, or imprisoned not more than 5 years, or both, and, in addition to or in lieu of such a criminal penalty, is subject to a civil money penalty of not to exceed $25,000 (or $15,000 in the case of a person other than the issuer of the policy) for each such prohibited act. ^{Sec. 1882. [42 U.S.C. 1395ss]} 

Our webpages that touch on this Issue:

• Part B – Doctors – How to sign up – Benefit
• Part B Late Enrollment Penalt
• End Stage Renal – Kidney Failure
• Age 65 – Tax Credits?
• Part A Hospital rules for zero premium
• Employer Plans vs Medicare - over or under 20 employees?