Medicare Advantage and End Stage Renal Disease

Jory Cross by Jory Cross | Licensed since 2012

This article was updated on: 09/15/2018

When your kidneys are no longer able to function at a level that supports daily living, you might have end-stage renal disease (ESRD). In most cases you can’t enroll in a Medicare Advantage plan when you have ESRD.

The Center for Medicare & Medicaid Services (CMS) defines end-stage renal disease as “permanent kidney failure that requires a regular course of dialysis or a kidney transplant.” According to the National Institutes of Health, diabetes is the most common cause of ESRD.

If you’re not familiar with Medicare Advantage plans, they provide an alternative way to get your Original Medicare (Part A and Part B) benefits – through a private, Medicare-approved insurance company instead of directly through the government. (Hospice benefits are still delivered directly through Part A.) Most Medicare Advantage plans also include prescription drug coverage, and many plans offer additional benefits such as routine vision services.

Am I eligible for the Medicare if I have end stage renal disease?

If you have end-stage renal disease (ESRD), even if you are under age 65, you may qualify for Original Medicare (Part A and Part B) as long as you meet all the following requirements:

  • Your kidneys are no longer functioning.
  • You’re on dialysis or you’ve had a kidney transplant.
  • You meet the qualifying work requirements under Social Security Administration (SSA) or the Railroad Retirement Board (RRB), or:
  • You’re already getting SSA or RRB benefits.
  • You’re eligible for SSA or RRB benefits.
  • You’re the spouse or dependent child of someone who meets the requirements of any of the previous three bullets.

Am I eligible for Medicare Advantage if I have end stage renal disease?

If you have ESRD and you’re enrolled in Original Medicare, ordinarily you won’t be eligible for a Medicare Advantage plan. However, some exceptions may apply:

  • You were already enrolled in a Medicare Advantage plan when you developed ESRD.
  • You’re already enrolled in a Medicare Advantage plan that is no longer being offered in your area; in this circumstance, you have a one-time-only option to enroll into another Medicare Advantage plan in your area.
  • You qualify for Medicare coverage through a Medicare Special Needs Plan (SNP – a type of Medicare Advantage plan) available in your area for people with ESRD.
  • You get health coverage(for example, through an employer or union plan) provided by an insurance company that also offers Medicare Advantage plans.
  • You have had a successful kidney transplant to treat your end-stage renal disease. Keep in mind, however, that Medicare coveragefor ESRD generally ends 36 months after a successful transplant for beneficiaries under age 65 who only qualified for Medicare coverage as a result of end stage renal disease.

If you would like more information about Medicare coverage for end-stage renal disease or to see if you qualify for a Medicare Advantage plan, I’m happy to answer your questions. You can request an email with information prepared just for you, or schedule a return phone call by clicking the appropriate link. To view plans you may qualify for in your area, click the “Compare Plans” button.

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