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Medicare Advantage and End Stage Renal Disease

October 6, 2016

End-stage renal disease (ESRD) is when the kidneys are unable to function at a level required for day-to-day life. The most common causes of ESRD, also known as stage-five chronic kidney disease (CKD), include diabetes and high blood pressure. For individuals with this condition, kidney damage is permanent, and requires dialysis or a kidney transplant for survival.

Medicare Eligibility by End-Stage Renal Disease

The Medicare end-stage renal disease (ESRD) program is a national health insurance program for individuals with ESRD. Individuals, even those under the age of 65, can be eligible for Medicare coverage if their kidneys no longer work, they require regular dialysis, or they have had a kidney transplant, and:

  • They have worked under Social Security, the Railroad Retirement Board (RRB), or for a Medicare-covered government employer for the required amount of time; or
  • They are already getting or eligible for Social Security or Railroad Retirement benefits, or
  • They are the spouse or dependent of an individual who meets either requirement above

In order to receive full benefits available under Medicare to cover certain dialysis and kidney transplant services, Medicare beneficiaries with ESRD will need to enroll in both Medicare Part A and Medicare Part B, called Original Medicare. After enrolling in Original Medicare, individuals then have the option of choosing plans from private insurance companies approved by Medicare for additional coverage.

Medicare Advantage Options for Medicare Beneficiaries with ESRD

Medicare Advantage plans are another way to receive your Medicare Part A and Medicare Part B benefits (except for hospice care, which Part A still provides), and may offer additional coverage such as prescription drug, dental, vision, and hearing.

In general, Medicare beneficiaries with end-stage renal disease cannot enroll in a Medicare Advantage plan. However, there are exceptions in which Medicare Advantage plan enrollment is possible for individuals with ESRD:

  • For Medicare beneficiaries who were already enrolled in a Medicare Advantage plan when they developed ESRD, they are able to keep their existing Medicare Advantage plan. They can also switch to another plan sold by the same insurance company that currently offers their Medicare Advantage coverage during certain enrollment periods, such as the Medicare Annual Enrollment Period.
  • Medicare beneficiaries, who have ESRD and are enrolled in a Medicare Advantage plan that is no longer available in their area, are provided a special election period to join another Medicare Advantage plan, from any private insurance company, available in their area.
  • A Medicare Special Needs Plan (SNP) is a type of Medicare Advantage plan available to those with specialized health needs due to chronic, severe, or debilitating medical conditions. For Medicare beneficiaries with ESRD who were not previously enrolled in a Medicare Advantage plan, they can enroll in a Medicare SNP if there is one available in their area for people with ESRD.
  • Some individuals with ESRD who had health care coverage with an employer or union through a Medicare Advantage carrier may be able to switch from their employer or union health care coverage to a Medicare Advantage plan offered by that carrier.
  • Enrollment in a Medicare Advantage plan may be possible after a successful kidney transplant. However, it is important to note that Medicare coverage will end 36 months after a successful kidney transplant if the Medicare beneficiary only is enrolled in Medicare as a result of ESRD.

For all Medicare beneficiaries with end-stage renal disease and enrolled in Medicare Advantage, their Medicare Advantage plan will be their primary health care coverage. The Medicare Advantage plan ID card should be used instead of the red, white, and blue card issued by Original Medicare for all doctor’s visits and health care services.