Under 65 with ESRD: What are your Medicare coverage options?

Victoria Burke by Victoria Burke | Licensed since 2011
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This article was updated on: 08/23/2018

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Do you have end-stage renal disease (ESRD)? That’s kidney failure where you need regular dialysis or a kidney transplant. Did you know you might qualify for Medicare, even if you’re younger than 65? You might have a few different Medicare plan options if you have ESRD.

Can I get Medicare if I have ESRD?

If you have end-stage renal disease (ESRD), you might qualify for Medicare – but you generally won’t get enrolled automatically into the program. And the types of Medicare plan options available to you might be somewhat limited.

However, you’ll probably qualify for Medicare before you turn 65 if you have ESRD. You can generally enroll in Original Medicare, Part A and Part B. Part A is hospital insurance, while Part B is medical insurance. Original Medicare comes with out-of-pocket costs, as discussed below.

Can I get Medicare Supplement Insurance Plan if I have ESRD under age 65?

Medicare Supplement Insurance plans are sold by private insurance companies, and may cover some of your Medicare out-of-pocket costs. Medicare Part A and Part B copayments, coinsurance amounts, and deductibles are some of the expenses that Medicare Supplement plans might cover. These plans are designed to supplement your Part A and Part B coverage.

If you’re under 65 with ESRD, however, you might not qualify for a Medicare Supplement plan. Federal law doesn’t require insurance companies to offer Medicare Supplement (also called Medigap) plans to those younger than 65.

However, if you have ESRD, you might want to know that some states may require insurance companies to offer at least one Medicare Supplement plan to Medicare beneficiaries under 65 years old. As of 2018, those states may include:

  • Colorado
  • Connecticut
  • Delaware
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • New Hampshire
  • New Jersey
  • New York
  • North Carolina
  • Oklahoma
  • Oregon
  • Pennsylvania
  • South Dakota
  • Tennessee
  • Texas
  • Wisconsin

(California and Vermont also require insurance companies to sell Medicare Supplement plans to Medicare beneficiaries younger than 65, but not if the applicant has ESRD.)

Can I sign up for a stand-alone Medicare Prescription Drug Plan if I have ESRD under age 65?

When you qualify for Medicare before you turn 65 with ESRD, you can generally enroll in a stand-alone Medicare Prescription Drug Plan that may cover the prescriptions you take. In fact, a Medicare Part D Prescription Drug Plan working alongside your Medicare Part A and Part B coverage and a Medicare Supplement plan may round out your coverage and meet most of your health-care needs.

Generally Original Medicare, Part A and Part B, includes only limited prescription drug coverage. Prescription drugs given to you as part of your treatment as a hospital inpatient are usually covered under Part A. Medications administered to you in an outpatient setting, such as a clinic or doctor’s office, may be covered under Part B.

What about most prescriptions that you’d take at home, such as you might need if you have ESRD? Usually you’d need to sign up for a stand-alone Medicare Part D Prescription Drug Plan to get this coverage. You’ll probably want to make sure the plan lists your medications in the plan formulary, or list of covered prescription drugs, before signing up. The formulary may change at any time. You will receive notice from your plan when necessary.

Can I sign up for a Medicare Advantage plan if I have ESRD under age 65?

If you’re younger than 65 with ESRD (end-stage renal disease), you might have limited access to Medicare Advantage plans. Medicare Advantage (Medicare Part C) generally gives beneficiaries an alternative way of getting Medicare Part A and Part B benefits (the exception is hospice care, which is covered under Part A instead of through the plan). Most Medicare Advantage plans include prescription drug coverage, and some plans offer additional benefits, like routine hearing services.

Most Medicare Advantage plans may not be available to those who have ESRD. However, there’s a special category of Medicare Advantage plans called Special Needs Plans (SNPs). One type of Medicare SNP is specifically designed for those with ESRD. All SNPs include prescription drug coverage, which might be important if you have ESRD.

To qualify for a Medicare Advantage plan, you need to be enrolled in Medicare Part A and Part B, and live within the plan’s service area. You must continue paying your Part B premium, along with any premium the plan may charge.

Are there any Special Needs Plans in your area that cover those with ESRD? One way you might find out is by clicking the Compare Plans button on this page and entering your zip code. Then, on the left side of the page, scroll down to Plan Type and click SNP.

If you’re under 65 with ESRD, and you’d like some help finding Medicare plan options that may work for you, I’m here to help. You can start by using the links below, next to my photo, to have me email you some personalized recommendations. Or, if you’d like to see some options now, use the Find Plans or Compare Plans buttons to begin comparing plans in your zip code.

Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.

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