Medicare or Other Health Plans for People who have Kidney Disease

By Beth Witten, MSW, ACSW, LSCSW

Most people with Medicare are at least 65 or disabled. Younger people may get it if they are on dialysis or have a kidney transplant. This blog post describes how and when you can get and lose Medicare, what it covers, and what it costs. It also describes other health plan options.

How can you get Medicare?
To get Medicare for kidney failure, you must start dialysis or get a kidney transplant AND have enough work credits:

    • In your work record
    • Under a birth parent, adopted parent, or stepparent’s work record.
    • Under a spouse’s work record

A child or young adult can use a parent’s work credits to get Medicare for dialysis or transplant if single and under 22, older than 22 but disabled before age 22, or age 22-25 single and getting at least half of his or her support from a parent who has enough work credits.

How many work credits are needed?
When you have kidney failure, you (or a parent or spouse) may need as few as 6 work credits earned in the last 3 years to get Medicare. Call Social Security at 1-800-772-1213 or sign-in to my Social Security to review your (or a parent or spouse’s) record at the Social Security Sign in Webpage.

How can I (or my parent or spouse) earn credits?
Earn $1,470 (in 2021) and pay FICA taxes to get 1 credit. You can earn up to four credits each year. How much income it takes to earn a credit goes up each year. Those on SSI and/or SSDI can use special Social Security programs to keep getting checks for a while when working and earning more credits.  See Social Security (SSA) Red Book under References for these programs.

What does Medicare cover and cost?
You could have Original Medicare or a Medicare Advantage plan. Both cover dialysis in a clinic or at home, training for home dialysis, transplants and many other healthcare needs. With Original Medicare you can see anyone that accepts Medicare. Medicare Advantage plans may limit where you get care. Most people get Part A free, but Part B has a premium. There are other out-of-pocket costs. Medicare Savings Programs can help pay those costs if you have low income and few assets.

If I get Medicare, when can it start?

    • There is a 3-month wait for Medicare when you do in-center dialysis.
    • It can start the first of the month if transplant is your first treatment.
    • It can start the first of the month dialysis started if you start training for home dialysis or in-center self-care before the end of your third month of dialysis.

How long will Medicare last and when will it end?
Medicare continues while you’re on dialysis and for 12 months after you stop dialysis for any reason other than transplant. If you recover kidney function, you may be at risk of kidney failure. If that happens during the 12 months after dialysis stops or if you get a transplant, you will have no gap in Medicare coverage. If you resume dialysis after 12 months, you will need to reapply for Medicare. Coverage post-transplant lasts at least 36 months—indefinitely if you’re 65 or older or disabled due to something other than ESRD. If your transplant fails after 36 months and you’re not 65 or disabled, you will need to reapply for Medicare.

Are you disabled from something else? Check in SSA’s “blue book” to see if you might qualify under any of the sections.

Children: For evidence of disability for dialysis, transplant, or other kidney conditions in children, see “Genitourinary Disorders” at Section 106.00. For chronic kidney disease before dialysis or transplant, Section 106.05 lists:

    • Chronic kidney disease with one of these lab results:
      • Creatinine is 3 mg/dL or greater
      • Creatinine clearance is 30 ml/min/1.72m2 or less
      • eGFR is 30 ml/min/1.72m2 or less
    • AND one of the following:
    • Major swelling (calf, eyes, lower back between the hips)
    • Slow growth based on age and BMI due to CKD
    • Dialysis
    • First year post-transplant or longer if problems exist

Adults: For evidence of disability for dialysis, transplant, or other kidney conditions in adults, see “Genitourinary Disorders – Adult” at Section 6.00. For chronic kidney disease before dialysis or transplant, Section 6.05 lists:

    • Reduced GFR on two occasions at least 90 days apart during a 12-month period
      • Creatinine is 4 mg/dl or greater
      • Creatinine clearance is 20 ml/min/1.72m2 or less
      • eGFR is 20 ml/min/1.72m2 or less

AND one of the following:

    • Renal bone disease and pain with imaging studies showing bone problems
    • Nerve damage (pain, numbness, weakness) in hands or feet
    • Fluid overload with high blood pressure (diastolic/lower number >110) and body swelling on at least two occasions at least 90 days apart during a 12-month period
    • Loss of appetite and weight loss (BMI <18) measured on two occasions at least 90 days apart during a 12-month period. 

What else can help pay for a young person’s dialysis or transplant?

    • A job-based plan can cover children and adults. That plan pays first, and Medicare pays second for 30 months. The clock starts the first month you could get Medicare for ESRD even if you don’t take it. After 30 months, the job-based plan may only pay second. Medicare needs to be in place by then to pay first.
    • If your family has low income and assets and you’re a citizen or in the U.S. legally, you can apply for:
      • Medicaid (Medi-Cal in California) that covers dialysis and transplant. A few states use state funds to pay for care for those who are not in the U.S. legally. Those states may pay for dialysis, but not transplant.
      • The Children’s Health Insurance Program (CHIP) to help pay for dialysis or transplant for your child if younger than 19.
    • TRICARE can help children in military families until they’re 21 (23 if a full-time student). From then until age 26, they can get healthcare through TRICARE Young Adult Program. It also covers active duty military members and spouses as well as national guard and retired members and their families.
    • A Medigap plan can help pay out-of-pocket costs for a child or adult who has Original Medicare. Federal law requires companies to sell you a Medigap plan for 6 months after you get Part B if you’re 65 or older. Some states have no plans for those under 65. Medigap plans don’t work with Medicare Advantage.
    • A state-run or the federal Marketplace may be an option for those who have no other health plan option. Plan premiums and out-of-pocket costs can be high. You may get help to pay premiums (any plan) and out-of-pocket costs (Silver plan) based on income.
    • An insurance broker may be able to help you get a private plan off the Marketplace if you can’t get a Marketplace plan. There is no help for premiums or other costs.

Finding and choosing a health plan can be a challenge. We hope this infromation has helped.

References:

 

Listen in to this podcast featuring Beth Witten, MSW, ACSW, LSCSW:
Paying for Dialysis or Transplant

Beth Witten, MSW, ACSW, LSCSW has been a renal social worker since 1978. She writes and presents on rehabilitation, health-related quality of life, and employment and kidney disease. She has worked with the MEI team since 1993 as a contributing writer, researcher, technical consultant, and community outreach expert. She served on the workgroup that developed the NKF KDOQI™ Clinical Practice Guidelines for chronic kidney disease and on a Rehabilitation Services Administration workgroup that developed a national training manual for vocational rehabilitation counselors. In 2010, Beth received the CNSW Lifetime Achievement Award.

Web ID 8016