Medicare is available for some children with end stage renal disease (ESRD). Some children may also be eligible for Medicaid and the Children’s Health Insurance Program.
Children who have other healthcare needs may be eligible for Medicaid or the Children’s Health Insurance Program (CHIP). To qualify for these programs, the family income of a child must fall within a certain range.
This article describes Medicare coverage for children with ESRD and out-of-pocket costs, as well as eligibility requirements and enrollment information. It also discusses Medicaid and CHIP, along with the coverage and eligibility requirements.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
To receive full healthcare coverage, a child with ESRD needs original Medicare, which consists of Part A, hospital insurance, and Part B, medical insurance. Part A covers the child for inpatient dialysis at the hospital, while Part B covers the following:
- outpatient dialysis in a Medicare-approved facility
- doctor services
- home dialysis supplies and equipment
- lab tests and other services related to dialysis
- most injectable drugs and their oral form for home dialysis
- certain home support services
- dialysis needed during travel
Children with ESRD also need Medicare Part D for prescription drug coverage that does not fall under Part B. Medications in this category would include immunosuppressive drugs and drugs that are only available in oral form.
Medicare coverage for children with ESRD ends at either of the time frames below:
The cost for Part A is a deductible of $1,484.
Part B costs include:
Part D costs include premiums, deductibles, coinsurance, and copays, all of which vary with the plan.
Children and their parents must meet the eligibility requirements, which state the child must be unmarried and under 22 years old. However, they could also be eligible if they are 22–26 years old and meet other requirements. In addition, one of the following conditions must apply for the child:
- They have had a kidney transplant.
- They need dialysis because their kidneys no longer work.
One of these conditions must apply to either parent:
- They have accumulated at least six credits within the most recent 3 years by working and paying Social Security taxes.
- They receive or are eligible for Social Security or Railroad Retirement Board benefits.
A parent may enroll a child with ESRD on the Social Security website or at a local Social Security office. To apply, they may need the documents below:
- a parent’s Social Security card
- the child’s Social Security card and birth certificate
- a form that provides medical evidence of ESRD
Children from low-income families may have health conditions unrelated to ESRD. They may need either short-term or long-term care.
They may need this care because of physical, intellectual, or mental disabilities, which may stem from conditions such as Down syndrome or autism.
Although the children are not eligible for Medicare, they may qualify for Medicaid or the Children’s Health Insurance Program (CHIP). According to Medicaid, more than 9 million children were enrolled in CHIP, while 36 million children were enrolled in Medicaid in 2018.
The states administer Medicaid and CHIP. Some use a Medicaid expansion program, a separate CHIP, or a combination of the two.
Medicaid expansion covers diagnosis, treatment, and prevention services for children from low-income families. CHIP provides health coverage equal to that of some common health plans.
Benefits differ among states, but all provide coverage for:
- dental care
- behavioral care
- well-baby visits
- well-child visits
Eligibility requirements for Medicare vary among states.
CHIP covers children from families with incomes too high to qualify for Medicaid but too low to buy private health insurance. To be eligible for CHIP, a person’s family income must fall within the required range, and be:
- under 19 years of age
- a United States citizen and resident of the state
People can use the Medicaid website to contact their state and see if their child is eligible for Medicaid or CHIP.
Medicare covers some children with ESRD. If they meet the eligibility requirements, they can receive coverage of services that relate to dialysis.
Children with other medical conditions may not be eligible for Medicare but may qualify for Medicaid and CHIP. These programs provide benefits for those with physical, intellectual, and mental disabilities.
Because these programs’ eligibility requirements vary among states, people may wish to contact their state Medicaid office to see if their child qualifies.