Not only is original Medicare a very important factor in obtaining health care coverage for an individual with End Stage Renal Disease (referred to as “ESRD”), Medicare insurance for individuals with ESRD is equally as important.  In a prior post we discussed the importance of enrolling in original Medicare Part A, but also stressed the importance of enrolling in original Medicare Part B in order to obtain the most complete coverage offered through original Medicare for individuals with ESRD.  Additionally, not only is it important to enroll in original Medicare Part A and Part B to obtain the most complete coverage offered by original Medicare, but enrollment in both original Medicare Part A and Part B are required before Medicare insurance , such as a Medicare Supplement or Medicare Advantage plan, can be purchased.  Medicare insurance for individuals with ESRD is much more complicated than an individual shopping for Medicare insurance for any other reason, such as disability or “aging in”, or turning 65.  Medicare Pathways can assist you in determining if there is a Medicare insurance policy available for a Medicare beneficiary that has obtained Medicare based on the diagnosis of ESRD.

Medicare insurance for individuals with ESRD is limited for individuals under age 65 – Medicare Supplement plans

Federal law does not require insurance companies to sell Medicare supplement (also known as “Medigap”)  policies to people under age 65.  There are 25 states that require insurance companies to sell Medicare Supplement policies to Medicare beneficiaries under age 65; however, of the 25 states that offer Medicare insurance for individuals under age 65,  California, Massachusetts and Vermont do not offer Medicare Supplements to anyone under age 65 with a diagnosis of ESRD.  The only state that offers Medicare Supplement plans to individuals under age 65 with a diagnosis of ESRD is Delaware. 

Medicare insurance for individuals with ESRD over age 65 – Medicare Supplement plans

If you are already enrolled in original Medicare Part A and Part B and have purchased a Medicare Supplement plan, the insurance company cannot drop you or cancel your policy if you later become eligible for Medicare based on a diagnosis of ESRD. (Original Medicare is different if you have ESRD.)   However, if you did not purchase a Medicare Supplement plan during your Open Enrollment Period, or when you turned 65, or prior to the diagnosis of ESRD was made, a Medicare Supplement plan is not an option for an individual who has been diagnosed with ESRD.  Any Medicare Supplement application written outside of guaranteed issue must go through underwriting and, unfortunately, ESRD is a disqualifying health condition.  In other words, the insurance company will deny any application for an individual who has ESRD and is not in an Open Enrollment Period, or guaranteed issue period.

Medicare insurance for individuals with ESRD – Medicare Advantage plans

Medicare Advantage plans are generally not available to people with ESRD. For most people with ESRD, original Medicare is usually the only option for health care coverage.  You may be able to join a Medicare Advantage plan if you are getting your health insurance benefits through an employer or group health plan, or through some organization that offers Medicare Advantage Plans.  While you are in a Medicare Advantage Plan, the plan will be the primary provider of your health care coverage.  In most Medicare Advantage plans, you usually get all your Medicare‐covered health care through the plan, and the plan may offer extra benefits. You may have to see doctors that belong to the plan or go to certain hospitals to get services. You will have to pay other costs, such as co-payments or co-insurance (also known as “cost-sharing”), for the services you get.  

Exceptions for enrollment in Medicare insurance for individuals with ESRD

There are a few other situations in which someone with ESRD can join a Medicare Advantage plan.  These include the following:

  • If you are already in a Medicare Advantage plan and develop ESRD, you can stay in the plan or join another plan offered by the same company in the same state.
  • If you have had a successful kidney transplant, you may be able to join a Medicare Advantage plan.
  • If your Medicare Advantage plan leaves Medicare or no longer provides coverage in your area, you can join another Medicare Advantage plan if one is available in your area and is accepting new members.
  • Medicare Advantage plans may choose to accept individuals with ESRD who are enrolling in a Medicare Advantage plan through an employer or union group under certain limited circumstances.

It is important to note that if you leave, or disenroll from your Medicare Advantage plan, you are subsequently left with only original Medicare as a means of coverage if you have ESRD.

Medicare insurance for individuals with ESRD – Special Needs Plans

Special Needs Plans limit all or most of their membership to people in certain institutions, or who are eligible for both Medicare and Medicaid , or for people with certain chronic or disabling conditions.  Some Medicare Advantage Special Needs Plans may accept individuals with ESRD. These plans must provide coverage for all of Medicare Part A and Part B health care and services. They also must provide Medicare prescription drug coverage (also known as “Part D”).  Some Special Needs Plans can be designed specifically for people with ESRD, or they can apply for a waiver to accept ESRD Medicare beneficiaries.  Special Needs Plans are available in limited areas, and only a few serve people with ESRD.  The Special Needs Plan must be designed to provide Medicare health care and services to people who can benefit the most from things like special expertise of the plan’s providers, and focused care management. Special Needs Plans also must provide Medicare prescription drug coverage.

Medicare insurance for individuals with ESRD – Prescription Drug Plans

Medicare Prescription Drug Plans (also known as “PDP” or “Part D”) are available to all people with Medicare, including those entitled because of ESRD or a disability.  In fact, Prescriptions Drug Plans are available to anyone on original Medicare, regardless of age or health conditions. While many drugs needed for treatment of ESRD are covered under original Medicare Part B (i.e., immuno-suppressive drugs needed following a kidney transplant), other drugs are not covered under Part B (i.e., drugs needed to treat related conditions, such as high blood pressure).  (For more information regarding prescription drug coverage by original Medicare please refer to Medicare Pathways article entitled Are Prescription Drugs Covered Under Original Medicare?) Thus, ESRD patients should consider enrolling in a Part D plan.  Everyone with original Medicare Part A and/or Part B is eligible to join a Medicare Prescription Drug Plan to help lower their prescription drug costs and protect against higher costs in the future. You must enroll in a Prescription Drug Plan in order to get prescription drug coverage.  When you enroll in a Medicare prescription drug plan, you pay a monthly premium plus a share of the cost of your prescriptions.  People with limited income and resources may be able for “Extra Help” paying for their costs in a Medicare Prescription Drug Plan premium, as well as their cost-sharing associated with the Prescription Drug Plan.

The importance of finding the most appropriate Medicare insurance plan

Medicare Pathways stresses the importance of purchasing the most appropriate Medicare insurance during your Open Enrollment Period when you are guaranteed issue of a policy regardless of your health conditions.  Purchasing a Medicare insurance policy during your Open Enrollment Period ensures you will be able to purchase the most appropriate coverage in case you would develop a serious health condition that would prohibit you from purchasing Medicare insurance later.  There are times, however, when an individual is Medicare eligible prior to 65 years of age, which limits Medicare insurance options.  Regardless of your age or medical situation, contact Medicare Pathways today to speak with a Benefit Advisor regarding the Medicare insurance options available to you in your area.  Medicare Pathways Benefit Advisors are highly trained agents who can evaluate your situation and help you sort through your insurance options.  Understanding original Medicare Part A and Part B can be confusing.  Trying to understand Medicare insurance can be overwhelming.  Medicare Pathways is ready to assist you in understanding original Medicare as well as your Medicare insurance options.  Medicare Pathways specializes in Medicare Supplement, Medicare Advantage and Prescription Drug Plans.  Therefore, the Benefit Advisors can assist you in enrollment in the plan(s) that are available to you.  Call 1-866-466-9118 to speak with a Medicare Pathways Benefit Advisor, or simply click here.

Medicare Pathways will help you make the most out of your Medicare!  We work with more than 20 different insurance companies which allows us to find the most affordable and most appropriate plan(s) for your Medicare insurance needs.

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