New to kidney dialysis? Told you need a transplant? Here's what you need to know about Medicare:

March 31, 2016

The following post is part one of a two-part series from Matthew Bahr, who has more than 10 years of experience in the healthcare finance field. You can learn more from him on his website, The Patient Financial Advisor. As always, if you have specific questions about your personal coverage or your transplant-related expenses, please contact an insurance representative or a transplant financial coordinator or social worker at your transplant center.

Alright, first, take a deep breath.

Being told you need to start dialysis is not an easy pill to swallow. So, be sure to ask plenty of questions to your doctor, even if you think the question is silly. Write them down so you'll remember to ask next time you see your provider. Go ahead and jot down their answers too. Once you have a better clinical understanding of what's going on, we can look at how Medicare will now play a role in your life.

Before we go further, I want to make sure we're all on the same page on what Medicare is and is not. You see, for reasons unknown (to me), someone thought it was a great idea to call a separate government sponsored program Medicaid.

Medicare and Medicaid. Yeah, no one will ever get them confused. [/sarcasm font]

For detailed information on the two, I'll direct you to this link here. But for this article to be most effective, you need only know the following.

  • Medicare has the “red, white, blue” card and is a federal program
    To be eligible, you must be 65 years old or have a qualifying disability
  • Medicaid is both a state and federal program
    It was created to help low-income individuals and families
    Also designed to help specific groups such as families, pregnant woman, children, caretakers, and elderly

Very good, now that we've clearly identified the two, the rest of this article we will be discussing Medicare only.

In part one of my two-part series, I want to talk about your eligibility for Medicare as a patient with ESRD. We’ll review how you become eligible, when the eligibility ends, and when it would resume.

Eligibility
There are 3 main ways to become eligible for Medicare due to end stage renal disease.

Initiate peritoneal dialysis (PD)
Once you begin peritoneal dialysis, you become eligible for Medicare. Your coverage would revert back to the 1st day of the month you initiated treatment. For example, if you started on 2/15/16, your Medicare eligibility would begin on 2/1/16.

Initiate hemodialysis (HD)
Hemodialysis is a bit different. You must be on HD for 3 consecutive months and then on the 1st day of your 4th month of treatment, you become eligible for Medicare. Using the same example as above, let's say you started HD on 2/15/16. February would count as your first month. February, March, April would be your three consecutive months, making you eligible for Medicare on May 1, 2016.

Receive a kidney transplant
If you are lucky enough to receive a transplant prior to starting dialysis, your Medicare eligibility would begin on the 1st day of the month you were transplanted. A very similar rule to that of PD. If you receive your transplant on 2/15/16, you Medicare eligibility would retro back to 2/1/16.

Those are the three ways you become eligible for Medicare, so moving forward in our discussion, let's assume that you now have Medicare coverage. The next thing I want to do is take a closer look at when your Medicare eligibility ends, how it continues, and when it would resume if you had previously lost it.

When your ESRD eligibility ends
Your Medicare coverage can terminate in a couple different ways. Both involve you no longer being diagnosed with ESRD (YAY!).

Your eligibility due to ESRD will end,

  • 12 months after the month you no longer require a regular course of dialysis
    If you end dialysis on 12/1/2015, you would lose your Medicare effective 1/1/16.
  • 36 months after the month you receive your kidney transplant
    If you receive your transplant on 12/1/2016, you would lose your Medicare effective 1/1/2020.

When ESRD eligibility continues
Now we know when we'll lose our eligibility, but what has to happen for that coverage to continue? Take a look at these three scenarios.

  1. If you resume a regular course of dialysis within 12 months after you stopped regular dialysis, there will be no interruption in coverage
  2. Your coverage will continue if you have a kidney transplant within 12 months after you stopped regular dialysis treatment
  3. If you start a regular course of dialysis within 36 months after transplant OR if you receive another kidney transplant within 36 months, your coverage will continue.

When eligibility resumes after previously losing it
Last piece on eligibility that I want to cover is what happens after you lose your Medicare due to ESRD, but then re-qualify.

  1. If you start a new regular course of dialysis or get a kidney transplant more than 12 months after you stopped getting regular dialysis, you must file a new application. HOWEVER, there is no 3 month waiting period if you are put on HD. Once you start dialysis again, you will be eligible for Medicare retro to the first of that month.
  2. If you have another kidney transplant more than 36 months after your previous kidney transplant, you must file a new application.

Now that you know how to qualify, keep, lose, and resume your Medicare coverage due to ESRD, in part two we'll be reviewing how Medicare will work with your other health insurance (assuming you already had coverage prior).

Until next time, good vibes always.

Matthew Bahr