What Is Medicare?

Medicare is government-provided health insurance for the following groups of U.S. citizens or permanent residents who have contributed enough Medicare taxes while they were working or have a spouse who contributed:

• 65 years of age and older
• Under 65 years of age with disabilities
• Diagnosed with End-Stage Renal Disease (permanent kidney failure requiring dialysis or kidney transplant)

What Type of Medicare Do I Need?

Under Medicare, End-Stage Renal Disease (ESRD) patients need Part A, Part B, and usually Part D to get all the benefits available to them. 

Medicare Part A does not usually require a monthly premium.  Part A Covers:

• Inpatient hospital care
• Inpatient care in skilled nursing facilities, hospice, and some home health care

There is a monthly premium (around $100 per month) for Medicare Part B.  After you pay a yearly deductible, Medicare will pay 80% of your monthly costs and you will be responsible for paying the remaining 20%.  If you have a secondary form of insurance, it can cover these additional costs.  Part B Covers:

• Doctor’s services, outpatient care including dialysis treatments, and home health care
• Some preventive services to help maintain health and to keep certain illnesses from getting worse

Medicare Part B will cover the majority of the drugs you may need during your dialysis treatment. However, it will not cover the medications you will need to get through your pharmacy including prescriptions for other health conditions such as high blood pressure, high cholesterol, or diabetes. These drugs can be covered by Medicare Part D which is offered by private drug companies approved by Medicare and requires a monthly premium in addition to Part B payment. 

What about Medicare Part C?

Medicare Part C is referred to as a Medicare Advantage Plan.  Medicare Advantage plans are health care plans offered by private companies that provide extra benefits and coverage.   With a Medicare Advantage Plan or ‘MA’ Plan, you use a health insurance card and may be restricted to see certain doctors or hospitals that are a part of your plan.  MA Plans include:

• Medicare Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPO)
• Private Fee-for-Service Plans
• Medicare Special Needs Plans

Not all ESRD patients are eligible to join a MA plan.  You may be eligible for Medicare Advantage if:

• Your MA Plan is offered through your employer or union health plan
• You have had a successful kidney transplant
• You already had a MA Plan when you were diagnosed with ESRD

ERSD patients are eligible for Medicare Special Needs Plans (SNP) if one is available in their area.   If you are interested in joining a MA Plan or have questions, you can contact the ESRD Network in your area.  The ESRD Networks are responsible for monitoring the quality of care in their specified region.  You can also contact Medicare at 1(800) 633-4227.

What is Medigap Insurance?

Medigap is a supplemental insurance policy that is designed to cover health care costs that Medicare doesn’t cover.  This means Medigap Insurance will cover the additional 20% costs that Medicare does not pay such as co-pays or deductibles.  You must have Medicare Part A and B to purchase a Medigap Policy, and Medigap policies require a monthly premium in addition to Part B. 

Unfortunately, Medigap is not currently available to all dialysis patients.  It is available to all patients over the age of 65, but only available to those under 65 in 31 states.

What if I Have Private Insurance?

After becoming eligible for Medicare, if you are covered by an employer or union group health plan, for the first 30 months of your dialysis treatment, your private insurance will act as the primary payer or primary insurance provider and Medicare will act as a secondary payer or secondary insurance provider.  This means that your private insurance will cover an upfront percentage of your healthcare costs, and Medicare will cover any supplemental expenses such as co-pays, premiums, or deductibles.   This is referred to as the ‘coordination period.’

If you maintain your private insurance coverage during this time, after the 30 month coordination period, Medicare will become your primary insurance, and your private insurance will automatically become secondary to Medicare.

If, for some reason, you lose your private coverage during the 30 month coordination period, Medicare will become your primary payer.   This means Medicare will cover the 80% of your medical costs, but you must rely on another form of insurance to pay the additional 20% not covered by your Medicare.

How Do I Sign Up for Medicare and When Will My Coverage Start?

To sign up for Medicare, you can apply to enroll by visiting your local Social Security office or calling them at 1 (800) 772-1213. A social worker or insurance coordinator at your dialysis clinic may also help you with more information regarding Medicare enrollment. 

For in-center hemodialysis patients, Medicare coverage starts the first day of the fourth month of your dialysis treatments.  

For home dialysis patients, Medicare is effective during the first month of treatment if you take part in a training program at a Medicare certified training facility or begin training within the first three months of your treatment and you plan to continue to dialyze at home. 

Please note: If you do not sign up for Medicare Part B when you first become eligible, there may be a fee for late enrollment.  Additionally, if you enroll in Medicare Part A without Medicare Part B or later drop Medicare B you may be only eligible to apply or reapply for Medicare B during open enrollment, which is January through February each year with coverage beginning July 1st. This could leave you with months of no insurance coverage.

Medicare coverage ends 36 months after you have a kidney transplant unless you are 65 or over or have been receiving Social Security Disability Benefits for at least two years for a non-kidney related condition.