Medicare Based on End-Stage Renal Disease (ESRD)
Individuals are eligible for premium-free Part A if they receive regular dialysis treatments or 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; or
- The first month a regular course of dialysis begins if the individual engages in self-dialysis training; or
- The month of kidney transplant; or
- Two months prior to the month of transplant if the individual was hospitalized during those months in preparation for the transplant. (CMS) * Publication 10128 Page 6 *
- If you have a Medi Gap plan before you are diagnosed with ESRD, you can keep it.
- 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.”
- If you are not in a guaranteed issue period, here’s the underwriting questions, so forget it.
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.
- 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 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 *
New Rule to promote at-home dialysis services
- kidney.org/home hemo
- fresenius kidney care.com/home-hemodialysis
- home dialysis.org/home-dialysis-basics
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 Plan F and Medicare Pay.
View Typical Summary of Benefits for MAPD
Average Billed Charges – 2017 Transplant
Kidney - $414k
click to enlarge and view course CA Health Line.org
Transplant Costs & Insurance - Kidney.org
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2022 Everything you want to know
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Medicare Advantage Plans
What is a Medicare MAPD Special Needs Chronic Condition #SNP – C-SNP Plan?
Medicare SNPs Special Needs Plans are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. Medicare.gov
A special needs plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals.A SNP may be any type of MA CCP, including either a local or regional preferred provider organization (i.e., LPPO or RPPO) plan, a health maintenance organization (HMO) plan, or an HMO Point-of-Service (HMO-POS) plan. There are three different types of SNPs:
- Chronic Condition SNP (C-SNP)
- Dual Eligible SNP (D-SNP)
- Institutional SNP (I-SNP) cms.govSpecialNeedsPlans *
Can I get my health care from any doctor, other health care provider, or hospital?
You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis).
Are prescription drugs covered?
Yes. All SNPs must provide Medicare prescription drug coverage (Part D).
Do I need to choose a primary care doctor?
Do I have to get a referral to see a specialist?
In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.
What else do I need to know about this type of plan?
A plan must limit membership to these groups:
1) people who live in certain institutions (like nursing homes) or who require nursing care at home, or
2) people who are eligible for both Medicare and Medicaid, or
3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or dementia).
Plans may further limit membership.
Plans will coordinate the services and providers you need to help you stay healthy and follow doctors’ or other health care providers’ orders.
Scan Foundation Summary on Chronic Care Act
home-delivered meals, transportation for nonmedical needs, pest control, indoor air quality equipment (e.g., air conditioner for someone with asthma), and minor home modifications (e.g., permanent ramps, widening of hallways or doorways to accommodate wheelchairs). Listening
telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.
Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.
That's why the premium is very low or ZERO!
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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] or ask a question below.
Video about Covered CA – if no Premium Free Part A – jump to 2:30 Medicare & the Marketplace (Covered CA
Links & Resources
(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:
LIPITOR can cause serious side effects
These side effects have happened only to a small number of people. Your doctor can monitor you for them. These side effects usually go away if your dose is lowered or if LIPITOR is stopped. These serious side effects include:
- Muscle problems. LIPITOR can cause serious muscle problems that can lead to kidney problems, including kidney failure. You have a higher chance for muscle problems if you are taking certain other medicines with LIPITOR.
- Liver problems. Your doctor should do blood tests to check your liver before you start taking LIPITOR and if you have symptoms of liver problems while you take LIPITOR. Call your doctor right away if you have the following symptoms of liver problems:
- Feel tired or weak
- Loss of appetite
- Upper belly pain
- Dark, amber-colored urine
- Yellowing of your skin or the whites of your eyes
- Learn More===> lipitor.com/side-effects
Signs of kidney injury could include dark urine, difficulty urinating or less frequent urination. “If you are on a higher dose of a statin and there is any issue with urination, call your doctor,” Steinbaum said. “Instead of a high-dose statin, we can use a lower-dose statin along with another type of cholesterol-lowering medication.”
Whatever you do, Mehta added, “do not stop taking statins abruptly. Have a conversation with your doctor to discuss your benefits and risks, and ask if your kidney function has been tested.” Read the whole article==> Web MD
Resources & Links
ESRD Info on Medicare Website
Transplant Costs & Insurance -Kidney.org
Medicare Publication #10128 End Stage Renal – 60 Pages – More than you ever wanted to know
Medicare Info for Children with End Stage Renal Disease (ESRD) From CMS.Gov
- ESRD – General Information
- Clinical Performance Measures (CPM) Project
- End-Stage Renal Disease (ESRD) Quality Improvement Initiative
- ESRD Network Organizations
- What causes kidney failure?
- Treatment of kidney failure
- New to dialysis
- Adjusting to kidney failure
- Complications of kidney failure
- Disaster preparedness
- Kidney failure/ESRD diet
Medi-Gap (Supplements) ♦
Pre-X for International Travel Plans ♦
Medicare Outside of USA Insbuy
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Rx costs under Medicare?
Oral End-Stage Renal Disease (ESRD) drugs: Medicare helps pay for some oral ESRD drugs if the same drug is available in injectable form and the drug is covered under the Part B ESRD benefit.
Transplant / immunosuppressive drugs. Medicare covers transplant drug therapy if Medicare helped pay for your organ transplant. Medicare won’t pay for any services or items, including transplant drugs, for patients who aren’t entitled to Medicare.
Part D may cover other transplant drugs that Part B doesn’t cover, even if Medicare didn’t pay for the transplant. If you have ESRD and Original Medicare, you may join a Medicare drug plan.
If you’re entitled to Medicare only because of ESRD, your Medicare coverage ends 36 months after the month of the transplant.
Medicare will pay for your transplant drugs with no time limit if you were already entitled to Medicare because of age or disability before you got ESRD or you became entitled to Medicare because of your age or disability after getting a transplant that was paid for by Medicare or private insurance that paid primary to your Medicare Part A (Hospital Insurance) coverage, in a Medicare-certified facility.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount for covered Part B prescription drugs that you get in a doctor’s office or pharmacy, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment of 20%. If your hospital is participating in a certain outpatient drug discount program (called “340B”), your copayment will be 20% of the lower price, with some exceptions. Doctors and pharmacies must accept assignment for Part B drugs, so you should never be asked to pay more than the coinsurance or copayment for the Part B drug itself.
If you get drugs that Part B doesn’t cover in a hospital outpatient setting, you pay 100% for the drugs, unless you have Part D or other prescription drug coverage. In that case, what you pay depends on whether your drug plan covers the drug, and whether the hospital is in your drug plan’s network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting that Part B doesn’t cover. Medicare.Gov * Provider Tips to get paid CMS.gov *
Related Pages in End Stage Renal Section