Medicare & You: End stage renal disease/kidney transplant eligibility & enrollment

Medicare & You: End stage renal disease/kidney transplant eligibility & enrollment


Hi, I’m Angela James at the Centers for Medicare & Medicaid Services. I’ve got some important information to share with you about Medicare coverage for people with End-Stage Renal Disease, also known as ESRD. ESRD is permanent kidney failure requiring dialysis or a kidney transplant. Learning that you have permanent kidney failure isn’t easy, but you can still take control of your life – and Medicare can help. If you have ESRD and already have Medicare because you’re 65 or older, or because you’re under 65 and disabled, Medicare will start paying for your dialysis treatments right away. If you’re under 65 and only eligible for Medicare because of ESRD, your Medicare coverage will usually start on the first day of the fourth month of your dialysis treatments. So you might be wondering what happens if you need a kidney transplant. Medicare covers kidney transplants done in a hospital that Medicare approves for kidney transplants. Medicare will also cover the full cost of finding the proper kidney for your transplant surgery, and the full cost of care for your kidney donor. To get the most comprehensive coverage for your kidney dialysis and kidney transplant services, you’ll need Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and possibly Medicare Part D (Prescription Drug Coverage). Now, some people get their Medicare through a Medicare health plan (like an HMO or PPO) and there are very specific rules for how those kinds of plans work with ESRD coverage. To learn more about Medicare coverage of ESRD, and how to get help with some of the health care costs that Medicare doesn’t pay, visit Medicare.gov.

8 thoughts on “Medicare & You: End stage renal disease/kidney transplant eligibility & enrollment

  1. The item or service reasonable or necessary and, therefore, covered by Medicare… 

    See Case No. 13-CV-990  Whitcomb v Sylvia Burwell Secretary of Health & Human Services.  http://www.leagle.com/decision/In%20FDCO%2020150601648/WHITCOMB%20v.%20BURWELL

    A remand sentence-four 42 U.S.C. § 405(g) reverses the Medicare Appeals Counsel's decision and is a “victory for the Plaintiff and terminates the litigation”.
    Under Federal Law, a prevailing litigant in a case against the United States Government is entitled to recover its attorney fees and costs, when the position asserted by the government was not substantially justified. 28 U.S.C. § 2412. "In the present matter this Court ruling recognizes that the government's refusal to cover a medical device for the management of ‪Whitcomb's diabetes was not supported in law or fact".

    Not only has a judge in the Medicare Office of Hearings and Appeals found coverage for CGM was appropriate, but the District Court of Wisconsin has ruled that claims cannot be denied based on the Article stating CGM is precautionary and therefore not covered…

    On May 26, 2015, the District Court for the Eastern District of Wisconsin ruled that the Secretary of Health and Human Services cannot deny coverage of a continuous glucose monitor based on a statement in an Article that such monitors are “precautionary.” The case reflects the arduous path that Type 1 diabetic Medicare beneficiaries endure while trying to secure coverage for a medical device that is considered the standard of care for Type 1 diabetics with hypoglycemic unawareness – a device widely deemed necessary to prevent life-threatening hypoglycemic events. The Medicare beneficiary had sought coverage from United Healthcare’s Secure Horizon’s Medicare Advantage Plan. Although United Healthcare covers CGM on a limited basis for non-Medicare beneficiaries, it does not cover CGM for Medicare beneficiaries.

    Through every phase of the multi-step Medicare administrative appeals process, the Plaintiff appealed the denial of a CGM that she got in April 2011. Although statutory regulations provide that an administrative law judge should issue a decision within 90 days of a request for an administrative hearing, 231 days passed until the Plaintiff received a favorable administrative law judge decision, i.e., February 2013. United Healthcare appealed the favorable decision and the Medicare Appeals Council reversed the decision asserting that the Medicare contractor’s local coverage determination (“LCD”) incorporated a Medicare Article that deemed CGM to be “precautionary.” Although Medicare regulations require the Council to issue a decision within 90 days of a request for review, the Council took approximately six months to render a decision, i.e., August 2013.

    The District Court, however, found that the LCD did not incorporate the Article by reference nor vise versa. Further, the Court noted the distinction between LCDs (which indicate whether a device is reasonable and necessary) and Articles (which address non-coverage information such as coding and payment). The Court reasoned that if a Medicare contractor could issue a coverage decision in an Article, it would subvert the LCD development process and would undermine Medicare beneficiaries’ ability to challenge a non-coverage policy as envisioned by Congress under Section 522 of BIPA.

    The Court remanded the matter to the Medicare Appeals Council to determine the Medicare beneficiary’s need for CGM based on her individual medical condition, i.e., without reference to the Article. The case underscores the challenges faced by Medicare beneficiaries seeking coverage of a device that is the standard of care, and the Office of Medicare Hearings and Appeals’ and Council’s failure to meet statutory deadlines, even for Medicare beneficiaries.

    The Secretary denying CGM on a one-line sentence that is unsupported in law or fact stating the CGM is "precautionary"  …  Since the majority of these life threating hypo-events requiring external assistance for recovery would be avoided… Not including the $800+ EMT rescue service and transportation fee. "The American Journal of Managed Care say" the costs for hypoglycemia visits were $17,564 for an inpatient admission, $1,387 for an ER visit." Doing the math:  Costs about $640 million a year.

  2. There are a few things to try
    drink plenty of water.
    eat watermelon – that helps prevent kidney disease naturally.
    try taking vitamin A and drink coconut water – these help cure kidney disease .
    cut down on tomato, cucumber, spinach and alcohol.
    (I discovered these and why they work on Jaylands kidney kit website )

  3. Is that help in india ?
    My mother have CKD problem, her urea is 190 and cretenine 8.98, doctor said for dialysis, is transportation possible for my mother, please help 😢

  4. Thank you for this video had I not seen this video I will not have to go about it my husband has been on dialysis for over a year and his deductible for his work insurance is extremely high we've been struggling with medical costs and his social worker has been no help but thanks to this video I've started the process so very much appreciate it

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