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Guide to Prescription Drug Coverage - Special Rules for People with End-Stage Renal Disease


What are the special rules for people with End-Stage Renal Disease (ESRD)?

If you have ESRD (permanent kidney failure requiring dialysis or a kidney transplant) and you are in the Original Medicare Plan, you can join a Medicare Prescription Drug Plan. You generally can’t join a Medicare Advantage Plan. However, if you are already in a Medicare Advantage Plan, you can stay in it or join another plan offered by the same company in the same state that includes Medicare drug coverage. Also, if you are a member of a health plan (like through a former employer or union) offered by the same company that offers one or more Medicare Advantage Plans, you may be able to join a Medicare Advantage Plan offered by that company. If you’ve had a successful kidney transplant, you may be able to join a Medicare Advantage Plan.

However this rule is changing. Beginning in 2021, you can join a Medicare Advantage plan (MA or MAPD) even If you have End-Stage Renal Disease. Read more on this site

If you have ESRD and are in a Medicare Advantage Plan and the plan leaves Medicare or no longer provides coverage in your area, you have a one-time right to join another Medicare Advantage Plan. You don’t have to use your one-time right to join a new plan immediately. If you change directly to the Original Medicare Plan after your plan leaves or stops providing coverage, you will still have a one-time right to join a Medicare Advantage Plan at a later date as long as the plan is accepting new members.

You may also be able to join a Medicare Advantage Plan called a Medicare Special Needs Plan for people with ESRD if one is available in your area.

Visit www.medicare.gov on the web for more information about ESRD and Medicare Advantage Plans. Under "Search Tools," select "Find a Medicare Publication" to view the booklet "Medicare Coverage of Kidney Dialysis and Kidney Transplant Services." You can also call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048.



(Primary Source: Centers for Medicare and Medicaid Services - Your Guide to Medicare Prescription Drug Coverage. This content may have been enhanced by this site to include further examples, explanations, and links.)