Medicare

Medicare is not just for people who are 65 and older. The program also helps Americans and legal residents of all ages who need dialysis or a kidney transplant. More than 80 percent of Americans with kidney failure, what Medicare calls End-Stage Renal Disease or ESRD, have Medicare. If you (or your spouse or parent) have worked long enough to qualify for Medicare, it will pay most of your treatment costs, plus some or all of the costs for hospital stays, doctors' visits, and other services. In addition, once you are on Medicare, it will cover other health problems not related to kidney disease. To learn more about how Medicare helps to pay for dialysis and kidney transplants click here.

Medicare has three parts:

What it covers:

Helps pay for hospital room and board, drugs and supplies while you are in the hospital, inpatient rehabilitation services, and lab tests, as well as for transplant testing and surgery, some nursing home care, hospice care, and some home health care.

Cost:

Premium: There is no monthly premium for this part of Medicare if you need dialysis and if you have enough work credits. If you are 65 or older, and you don't have enough credits you may be able to get coverage by paying a premium. How much you pay depends on how may work credits you have.

Deductible and Co-insurance: Everyone in Part A must pay a specific amount of money, called a deductible, each benefit period before Medicare will pay (the deductible in 2021 is $1,408). A new benefit period starts after you've been out of the hospital, nursing home, or rehabilitation center for 60 days. If you have a long hospital stay you may have to play some for each day too (co-insurance). Learn about the deductible and co-insurance costs for Part A.

What it covers:

Helps pay for most of the other services and supplies not covered by Medicare Part A. This includes important services that people with kidney failure need, including doctors' visits, dialysis, outpatient hospital care. For ESRD patients, Medicare Part B covers 80% of the cost of outpatient dialysis services and immunosuppressant medication for transplant recipients.

Cost:

Premium: There is a monthly premium for Part B services (starting at $148.50 in 2021)
*You do not have to enroll in Part B at the same time you enroll in Part A, but your monthly premium will be 10% higher for every 12 months you delay enrolling in Medicare Part B from the time you were eligible. You will also only be able to enroll in Part B from January through March during open enrollment each year and coverage will not start until July 1st.

Deductible: There is an annual deductible ($198 in 2021).

*IMPORTANT FOR PEOPLE NEEDING DIALYSIS OR A KIDNEY TRANSPLANT*

• You need Medicare Part A and B if you want Medicare to help pay for dialysis and transplant services.
• For kidney transplant recipients, coverage for immunosuppressants is provided by Medicare Part B.
• You must be enrolled in at least Part A in the month you have a kidney transplant to have Medicare Part B ever pay for your immunosuppressant drugs.

What it covers:

Part D is a prescription drug plan for Medicare recipients. For most, Part D is voluntary, so if you have prescription coverage already through an employer health plan and it is "creditable coverage", then you do not need Part D. Your employer will send out letters each fall; if your employer health plan offers creditable coverage you can choose to join Medicare Part D or stay with a drug insurance plan you already have.

Part D plans are offered by private insurance companies and each company's plan may cover different drugs. Before you sign up for any plan, be sure to find out if it covers the drugs you take now and those your doctor thinks you may need in the future. Choosing a Part D plan that is right for you could save you a lot of money on the cost of your medications. Search for and compare Part D plans. If you would like personal assistance enrolling in a Part D plan, gather your list of medications and contact your state's SHIP Medicare Counselors at: www.shiptacenter.org

IMPORTANT NOTE: Once you are on Medicare, you have 6 months to enroll in Part D. If you do not sign up for Part D at this time you will have to pay a late enrollment penalty and you will only be able to enroll during Medicare Part D open enrollment each year between October 15–December 7.

Cost:

The amount you pay depends on your income and assets and whether the drugs you need are covered by your plan. Most plans have a monthly premium (varies), deductible, as well as co-pays for drugs. Co-pay costs may vary depending on the tier or class of drug you are taking.

Coverage Gap - The Donut-Hole:
Most Medicare Prescription Drug Plans have a coverage gap commonly referred to as the "donut hole". This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2021, once you and your plan have spent $4,130 on covered drugs (the combined amount plus your deductible), you're in the coverage gap. The gap ends once you reach $6,550 in out-of-pocket expenses.

In 2021, once you reach the coverage gap you'll pay:

• 25% of the plan's cost for covered brand-name prescription drugs during the coverage gap.
  • Almost the full price of the drugs will count as out-of-pocket costs to help you get out of the coverage gap. Learn more here. 
• 25% for generic drugs during the coverage gap.
  • The coverage for generic drugs works differently from the discount for brand-name drugs. For generic drugs, only the amount you pay will count toward getting you out of the coverage gap.

For people on dialysis:

• Medications that you receive during dialysis are covered by Medicare Part B as part of the "bundled payment" for dialysis treatment such as epogen, vitamin D, IV iron.

For transplant recipients:

• Although immunosuppressant medications are covered by Medicare Part B, you will still need to have drug coverage for your other medications. Medicare Part D would help pay for other medications that are not covered by Medicare Part B.
• For transplant patients whose immunosuppressant drugs are not covered by Medicare Part B due to lack of eligibility they may be able to get help from Part D for those drugs if they are covered by the plan.

For more on Medicare for dialysis and transplant recipients visit:

• Frequent Asked Questions about Medicare
• What Dialysis Patients Should Know About Transplant