Medicare Coverage of  End Stage Renal Disease? (ESRD) 
Chronic Kidney Disease?

 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 * 

Part A & B Sign Up?

Pros – Cons – Complicated FAQ’s Research on staying with under 65 plan?  Covered CA? 

Medi-Gap policy?

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   *

davita.com/insurance-financial-management

See our page on what Plan F and Medicare Pay.

View Typical Summary of Benefits for MAPD

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

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:

  1. Chronic Condition SNP (C-SNP)
  2. Dual Eligible SNP (D-SNP)
  3. 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?

Generally, yes.

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.

SNP Benefits
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Chronic Condition Special Needs Plans C SNP

Scan Foundation Summary on Chronic Care Act 

Forbes  * Commonwealth Fund - Social Services

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.

Learn More

  Part C & D Enrollment Periods

SNP is all the time
Part C & D Enrollment Periods

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Video

Video understanding medicare advantage mapd

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.

That's why the premium is very low or ZERO!

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 

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:

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

People who take high doses of popular cholesterol-lowering drugs called statins may be more likely to develop kidney problems, a new study suggests.

“If you are concerned about your statin then go talk to your doctor,” he said. “Do not panic. There are both urine and blood tests your doctor can use to monitor your kidneys.”

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

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Rx costs under Medicare?

Part D Rx – Shop Plans    Immunosuppressant Rx can run $5 to 13k You Tube *

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Rx coverage under Part B 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

Medicare covers the substantial costs associated with End Stage Renal Disease (ESRD) for the vast majority of kidney patients. How will this coverage change under the newly implemented Affordable Care Act, also known as Obamacare?

Related Pages in End Stage Renal  Section

 

18 comments on “End Stage Renal – Kidney Failure

  1. https://www.latimes.com/california/story/2020-12-09/dialysis-industry-political-spending-california-lawmakers-ballot-measures

    But dialysis companies can get higher reimbursements from private insurers than from public coverage. And one way to keep dialysis patients on private insurance is by giving them financial assistance from the American Kidney Fund, which helps nearly 75,000 low-income dialysis patients across the country.

    The fund gets most of its money from DaVita and Fresenius Medical Care, the two largest dialysis companies in the country. The fund does not disclose its donors, but an audit of its finances reveals that 82% of its funding in 2018 — nearly $250 million — came from two companies.

    tight relationship between the American Kidney Fund and the companies that provide dialysis, which filters the blood of people whose kidneys are no longer doing the job.
    https://californiahealthline.org/news/dialysis-patients-panic-as-financial-life-raft-becomes-unmoored/

    https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis

    • If you’re getting a kidney transplant

      Medicare coverage can begin the month you’re admitted to a Medicare-certified hospital for a kidney transplant (or for health care services that you need before your transplant) if your transplant takes place in that same month or within the next 2 months.

      Example: Mr. Green will be admitted to the hospital on March 11 for his kidney transplant. His Medicare coverage will begin in March. If his transplant is delayed until April or May, his Medicare coverage will still begin in March.

      If your transplant is delayed more than 2 months after you’re admitted to the hospital (for the transplant or for health care services you need before your transplant), Medicare coverage can begin 2 months before your transplant.

      Example: Mrs. Perkins was admitted to the hospital on May 25 for some tests she needed before her kidney transplant. She was supposed to get her transplant on June 15. However, her transplant was delayed until September 17. Therefore, Mrs. Perkins’ Medicare coverage will start in July—2 months before the month of her transplant. https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf#page=10

      See page 9 if you want to qualify based on getting dialysis

  2. If I have a transplant and I get better, do I lose my Medicare?

    If so, can I get a “Special Enrollment” back into an ACA/Obamacare plan?

    • End-Stage Renal Disease (ESRD)—Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

      You can get Medicare no matter how old you are if your kidneys no longer work, you need regular dialysis or have had a kidney transplant,
      https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf?

      Having kidney failure means that:

      85-90% of your kidney function is gone
      your kidneys don’t work well enough to keep you alive
      https://www.kidney.org/atoz/content/KidneyFailure

      When the beneficiary first enrolls in Medicare based on ESRD, Medicare coverage usually starts:

      1. On the fourth month of dialysis when the beneficiary participates in dialysis treatment in a dialysis facility.

      2. Medicare coverage can start 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 to learn how to do self-dialysis treatment at home;
      The beneficiary begins home dialysis training before the third month of dialysis; and
      The beneficiary expects to finish home dialysis training and give self-dialysis treatments.
      Example: If the beneficiary starts home dialysis training in a Medicare approved facility, or if a course of home self-dialysis training is begun before the third month of dialysis, or if the beneficiary is expected to finish home dialysis training and perform self-dialysis on July 17th, the Medicare entitlement date would be July 1st.

      3. Medicare coverage can start 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.

      Example: If the beneficiary has a kidney transplant on July 17th, the Medicare entitlement date would be July 1st.

      4. Medicare coverage can start 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.

      Example: If on July 17th the beneficiary starts pre-surgical health care services that are needed prior to a kidney transplant and the transplant is performed on September 4th, the Medicare eligibility date would be July 1st, since the transplant was performed within two months of the pre-surgical services.

      5. Medicare coverage can start 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.

      Example: The beneficiary was admitted to the hospital on May 25th for some tests that are needed before a kidney transplant. The transplant was to be on June 15th; however, the transplant was delayed until September 15th. Therefore, the beneficiary’s Medicare coverage will start on July 1st, two months before the month of transplant.https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/End-Stage-Renal-Disease-ESRD/ESRD.html

      https://www.kidney.org/sites/default/files/docs/esrd_medicare_guidelines.pdf

      Kidney failure refers to temporary or permanent damage to the kidneys that results in loss of normal kidney function. End-stage renal disease (ESRD) is when the kidneys permanently fail to work. https://stanfordhealthcare.org/medical-conditions/liver-kidneys-and-urinary-system/kidney-failure.html

      • If I have a transplant and I get better, do I lose my Medicare?

        If so, can I get a “Special Enrollment” back into an ACA/Obamacare plan?

        • If you’re getting a kidney transplant

          Medicare coverage can begin the month you’re admitted to a Medicare-certified hospital for a kidney transplant (or for health care services that you need before your transplant) if your transplant takes place in that same month or within the next 2 months.

          Example: Mr. Green will be admitted to the hospital on March 11 for his kidney transplant. His Medicare coverage will begin in March. If his transplant is delayed until April or May, his Medicare coverage will still begin in March.

          If your transplant is delayed more than 2 months after you’re admitted to the hospital (for the transplant or for health care services you need before your transplant), Medicare coverage can begin 2 months before your transplant.

          Example: Mrs. Perkins was admitted to the hospital on May 25 for some tests she needed before her kidney transplant. She was supposed to get her transplant on June 15. However, her transplant was delayed until September 17. Therefore, Mrs. Perkins’ Medicare coverage will start in July—2 months before the month of her transplant. https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf#page=10

          See page 9 if you want to qualify based on getting dialysis

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