Understanding Dialysis Medicare Coverage for ESRD

Original Medicare is government-sponsored health insurance that provides health coverage to qualified U.S. citizens and legal residents. Medicare comes in several parts that cover different services, Medicare parts A, B, and D, along with a comprehensive plan option called Medicare Advantage, or Medicare Part C. Thanks to the Cures Act, Medicare Advantage is available for the first time for people with end stage renal disease (ESRD) during 2020 open enrollment in October, with plans going into effect January 2021. 
 

You are eligible for Medicare at age 65—or earlier if you have certain health conditions. People who are diagnosed with end stage renal disease (ESRD) at any age are usually eligible for Medicare after 3 months of dialysis or after completing home dialysis training. Talk to your insurance coordinator to find out more.


Understanding Medicare: Parts A, B, C, & D

MEDICARE PART A

Offered by: Government
Type of coverage: Hospital coverage
What it covers: Inpatient hospital care, hospice care, and some nursing home and home healthcare
Usually chosen: Together with Medicare Part B
Premium: No
Coverage: 80%
Annual Deductible: Yes

MEDICARE PART B

Offered by: Government
Type of coverage: Medical coverage
What it covers: All outpatient care, including dialysis services and doctor visits

Usually chosen: Together with Medicare Part A
Premium: Yes
Coverage: 80% 
Annual Deductible: Yes

MEDICARE PART C

Offered by: Private companies, contracted through Medicare
What it covers: Hospital and medical coverage, plus many plans offer coverage for prescription drugs and other benefits not typically covered by Medicare such as dental, vision, and hearing.

Replaces: Separate traditional Medicare Parts A, B, and D, plus Medigap plans.
Premium: Yes—$0 or may be lower than Part B
Coverage: Co-pays and co-insurance, with a cap on annual out-of-pocket costs
Annual Deductible: None for many plans, but there may be a deductible for prescription drug coverage.

MEDICARE PART D

Offered by: Private companies, contracted through Medicare 
What it covers: The cost of prescription medications that aren't covered by Part B which may cover dialysis or transplant medications

Usually chosen: Chosen with Parts A and/or B. Cannot be combined with Part C or a Medigap plan that includes drug coverage. 
Premium: Yes—varies by income 
Coverage: Co-pays that vary, based on the drug tier and your total spend on drugs annually. 
Annual Deductible: Usually, though some Part D plans don't have a deductible


Before you make any health insurance changes, talk to your insurance coordinator

It’s helpful to make sure you understand all of the benefits and costs for each insurance option before you make any changes. Sometimes, a plan with a higher premium might save you more money overall—or a plan with a lower deductible can wind up costing you more.


Have insurance through your employer?

Your current plan might be the best coverage for you. If you decide to switch to Medicare, you can keep your employer group coverage and Medicare together for 30 months. After that, Medicare becomes your primary insurance, and you can keep your employer plan as secondary insurance. Talk you your insurance coordinator about the best option for you.

NEW IN 2020: MEDICARE ADVANTAGE FOR PEOPLE WITH ESRD

New legislation allows Medicare-eligible people diagnosed with ESRD to enroll in Medicare Advantage 
(Medicare Part C). Open enrollment begins October 15, 2021. Ask your insurance coordinator for details.
LEARN THE BASICS





UNDERSTAND­ING DIALYSIS TREATMENT COSTS

Find out more about coverage for dialysis and key insurance terms.
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