Original Medicare pays for treatment associated with ESRD (End Stage Renal Disease). If you have been diagnosed with ESRD obtaining coverage for treatment is a significant concern. Luckily, original Medicare provides coverage for treatments associated with ESRD. If you have been diagnosed with ESRD, you are eligible for original Medicare Part A (hospital coverage), no matter how old you are, if your kidneys no longer function, and you get a regular course of dialysis or have had a kidney transplant, and,
- You have worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee; or
- You are getting or are eligible for Social Security, railroad retirement, or Federal retirement benefits; or
- You are the spouse or dependent child of a person who has worked the required amount of time, or is getting benefits from Social Security, Railroad Retirement, or Federal retirement.
NOTE: Original Medicare pays for treatment associated with ESRD; however, you must also file an special application regarding ESRD and meet any waiting periods that apply. Original Medicare entitlement based on ESRD is different from entitlement based on a disability.
Medicare pays for treatment associated with ESRD but for the most complete coverage you should enroll in original Medicare Part B as well.
If you get original Medicare Part A, you can also get original Medicare Part B (medical coverage). Enrolling in original Medicare Part B is optional; however, if you do not enroll in original Medicare Part B when you are initially eligible for original Medicare Part A, then you must wait until a Medicare General Enrollment Period to apply and you may have to pay a penalty. There is a monthly premium for original Medicare Part B, which is $104.90 in 2013. You will need both original Medicare Part A and Part B to have most complete original Medicare coverage possible for dialysis and kidney transplant services. By obtaining both original Medicare Part A and Part B is significant in how original Medicare pays for treatment associated with ESRD.
Medicare pays for treatment associated with ESRD even if you are already covered by original Medicare when you are diagnosed with ESRD.
If you are already enrolled in original Medicare Part A and Part B based on age or disability, then original Medicare will pay for treatment associated with ESRD. Contact your local Social Security office regarding your diagnosis of ESRD. Social Security will need your doctor or the dialysis facility to complete Form CMS‐2728 to document that you have ESRD. Thus, Medicare pays for treatment associated with ESRD, but you must notify Medicare of your diagnosis of ESRD. It is important to note with regard to the original Medicare Part B penalty that if you are already paying a higher Part B premium because you did not enroll in original Medicare Part B when you were first eligible, you will no longer have to pay the penalty when your entitled to original Medicare is based on the diagnosis of ESRD. You will only have to pay the original Medicare Part B premium of $104.90.
If Medicare pays for treatment associated with ESRD, when will coverage begin?
- Medicare coverage will begin on the first day of the fourth month of a regular course of dialysis. This initial three-month period is called the qualifying period.
- Medicare coverage will begin the first month of a regular course of dialysis treatments if you participate in a self‐dialysis training program in a Medicare‐approved training facility during the first three months you get a regular course of dialysis and your doctor expects you to finish training and be able to do your own dialysis treatments.
- Medicare coverage begins the month you receive a kidney transplant or the month you are admitted to an approved hospital for transplant or for procedures preliminary to a transplant, providing that the transplant takes place in that month or within the two following months.
- Medicare coverage can start two months before the month of your transplant if your transplant is delayed more than two months after you are admitted to the hospital for the transplant or for health care services you need before your transplant.
Medicare pays for treatment associated with ESRD as long as you require certain treatments.
If you have original Medicare coverage and ESRD is the only reason you are covered by original Medicare (i.e., you are not age 65 or over or disabled under Social Security rules), original Medicare coverage will end if any of the following occur:
- You do not require a regular course of dialysis for 12 months, or
- 36 months have passed after the month of the kidney transplant.
Original Medicare coverage for ESRD will continue without interruption based on the following:
- If you resume a regular course of dialysis or get a kidney transplant within 12 months after you stopped getting a regular course of dialysis, or
- You start a regular course of dialysis or receive another kidney transplant before the end of the 36‐month post‐transplant period.
Original Medicare coverage will resume with no waiting period if any of the following occur:
- You start a regular course of dialysis again or get a kidney transplant more than 12 months after you stopped getting a regular course of dialysis, or
- You start a regular course of dialysis or get another kidney transplant more than 36 months after the month of a kidney transplant.
It is important to note that for coverage to resume, you must file a new application for this new period of original Medicare entitlement.
While Medicare pays for treatment associated with ESRD, but what if I have other coverage such as employer or union group health plan coverage?
In general, original Medicare is the secondary payer of benefits for the first 30 months of original Medicare eligibility (known as the 30‐month coordination period) for people with ESRD who have employer or union group health plan coverage. If your group health plan coverage will pay for most or all of your health care costs you may want to delay enrolling in original Medicare Part A and Part B until the 30‐month coordination period is over. If you delay enrollment, you will not have to pay the original Medicare Part B premium for coverage you do not need yet. After the 30‐month coordination period, you should enroll in original Medicare Part A and Part B. Note: If you will soon receive a kidney transplant, get the facts about eligibility and enrollment before deciding to delay.
What if I do not meet the criteria to qualify for Medicare?
If you do not qualify for original Medicare, you may be able to get help from your state Medicaid agency to pay for your dialysis treatments. Your income must be below a certain level to receive Medicaid. In some states, if you have Medicare, Medicaid may pay some of the costs that Medicare does not cover. To apply for Medicaid talk with the social worker at your hospital or dialysis facility, contact your local Department of Health and Human Services, or contact social services.
Medicare Pathways wants you to be as informed as possible regarding your original Medicare coverage and your original Medicare rights. It is important to understand how original Medicare pays for treatment associated with ESRD (End Stage Renal Disease) and what happens if you stop and/or restart treatment. It is important to understand original Medicare coverage and the function of original Medicare Part A and Part B and each parts’ role in obtaining coverage for any and all conditions, but especially if you have a diagnosis of ESRD. It is equally important that you understand Medicare insurance and the stipulations and/or regulations associated with original Medicare and a diagnosis of ESRD. Contact a Medicare Pathways Benefit Advisor to discuss your Medicare insurance options by calling 1-866-466-9118, or by clicking here, and you will be redirected and asked to complete a short, simple form. Then a Medicare Pathways Benefit Advisor will contact you.
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