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Medicare Advantage And End Stage Renal Disease: What You Should Know

By John McGuire
End stage renal disease (ESRD) is a complex condition that requires specialized coverage. Fortunately, Medicare Advantage offers Special Needs Plans for people with ESRD.

Few pre-existing conditions are more complex and require as much intensive care as ESRD. In some situations, it can be difficult to find insurance plans that will cover conditions like ESRD. The good news is that there are specific plans in the Medicare Advantage system that are geared towards people with special needs, such as ESRD. Here, we cover everything you should know about Medicare Advantage and ESRD, using the official U.S. government website for Medicare as a guide.

Can You Enroll in Medicare Advantage With ESRD?

As of January 2021, you can enroll in Medicare Advantage with ESRD. Here’s how it works.

Medicare Advantage is a system of insurance that was developed as an alternative to Original Medicare (Parts A and B). Each Advantage plan is run by a private company who must adhere to Medicare rules. 

The savings that many Medicare Advantage beneficiaries enjoy come from the pooling of resources into networks of care. Every Advantage plan must cover the same services offered by Medicare Part A and Part B, and many offer drug coverage as well as other benefits like vision, hearing, and dental services.

There is a type of Medicare Advantage plan called a Special Needs Plan. These plans organize medications, services, and benefits around the particular needs of the populations that they serve. Chronic condition Special Needs Plans (C-SNPs) treat people with defined chronic conditions such as diabetes, stroke, cancer, and ESRD.

The specific Special Needs Plans available in your area will vary, but you can qualify for ESRD Special Needs Plans at any age. The official U.S. government website for Medicare states that you are eligible if:

  • Your kidneys do not work
  • You require regular dialysis
  • You’ve had a kidney transplant

You can also qualify for an ESRD Special Needs Plan if:

  • You've worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee
  • You're currently receiving or eligible for Social Security or RRB benefits
  • You're the spouse or dependent child of a person who meets the above two requirements

As of January 2021, those who have ESRD can choose either Original Medicare (Parts A and B) or a Medicare Advantage Plan when making their Medicare coverage selections. 

If you're on dialysis, your Medicare coverage will usually begin on the first day of the fourth month of your dialysis treatments. However, your coverage can begin during the first month of your dialysis treatments if:

  • You complete a home dialysis training program at a Medicare-certified training facility during the first 3 months of your regular dialysis course
  • Your doctor expects you to finish training and be able to administer your own dialysis treatments

If you're receiving a kidney transplant, your Medicare coverage will depend on the timing of your transplant. If you're admitted to a Medicare-certified hospital for either your transplant or medical services you need prior to your transplant and your transplant will take place during the same month you're admitted or within the next 2 months, your coverage will begin during the first month you're admitted. 

However, if your transplant is delayed by more than 2 months after your initial hospital admission, your Medicare coverage will begin 2 months prior to your transplant. 

Those with ESRD can also enroll in a Medicare Advantage plan during Medicare Open Enrollment, which extends from October 15 to December 7 yearly. 

In some states, Special Needs Plans are only offered in certain counties. The contracts for Special Needs Plans are subject to change because the companies that offer them have the option to leave the Medicare system every year. It’s important to check with the plan to see if the providers and facilities you plan to use are part of the plan’s network.

Getting dialysis services in the case of an emergency requires that you call your Medicare Advantage provider to find the most appropriate facility to use in your area. You may still be eligible for out-of-area coverage for dialysis, but this should be coordinated through your plan.

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Interested in learning more about Medicare, Medigap, and Medicare Advantage plans? WebMD Connect to Care Advisors may be able to help.