End-stage renal disease (ESRD) is the last stage of kidney failure. If someone has ESRD, they will need dialysis or a kidney transplant in order to survive.
ESRD Medicare works differently than other types of Medicare, including eligibility requirements.
Medicare provides health insurance coverage for various dialysis services for its beneficiaries.
End-stage renal disease (ESRD) is the last stage of kidney failure. This means that specific medical interventions are needed in order for the patient to survive. To treat kidney failure, one option is dialysis. But is this covered by Medicare? As well, what if someone has yet to enroll in Medicare due to age but has a failing kidney?
As it turns out, Medicare has special policies when it comes to ESRD. For one, eligibility requirements are different for people with ESRD. Someone does not have to be 65 or older to qualify. Other conditions must be met instead in cases of end-stage renal disease.
Many health care services are covered by Medicare, both under Original Medicare plans as well as Medicare Advantage (MA) plans. However, there are a number of factors that come into play with exactly how ESRD Medicare coverage functions.
What is End Stage Renal Disease?
End-stage renal disease (ESRD) is also known as kidney failure. ESRD is the last stage of chronic kidney disease. This means that one’s kidneys have stopped functioning entirely. In this scenario, without medical interventions such as a kidney transplant or dialysis treatments, one cannot survive.
While there is no cure for ESRD, many people with ESRD go on to live full and healthy lives with the help of dialysis or a kidney transplant.
What is Dialysis?
Dialysis is a form of treatment for kidney failure. There are two main types of dialysis: peritoneal dialysis and hemodialysis. Each one performs normal kidney functions, including filtering waste and excess fluid from the blood.
Hemodialysis, or “HD”, uses a machine to cleanse the blood. This can be done at home or at a dialysis center. Peritoneal dialysis cleanses the blood using the lining of the abdomen with a cleaning solution, dialysate. This type of dialysis can be performed at home or at work, given there is a private, clean area to do so.
Understanding Medicare Coverage for Dialysis
While an individual typically becomes eligible for Medicare at age 65, the federal Medicare program works a little differently when it comes to ESRD.
Medicare eligibility works differently in cases of ESRD. Anyone can be eligible for Medicare if all the following criteria are met:
The kidneys no longer work
Routine dialysis is needed or the patient has received a kidney transplant
As well, at least one of the following must be true:
They’ve worked the required time under Social Security, the Railroad Retirement Board (RRB), or as a government employee
They’re currently receiving, or are eligible for, Social Security or Railroad Retirement benefits
They’re the spouse or dependent child of someone who meets either of the aforementioned criteria
The official federal government website for Medicare recommends contacting Social Security for additional information. Those who receive benefits from the Railroad Retirement Board (RRB) should call 1–877-772‑5772.
When Medicare Coverage Starts for ESRD
Eligibility for Medicare coverage due to ESRD is different from other types of Medicare eligibility. If someone is eligible for Medicare because of ESRD and doesn’t enroll immediately, their coverage could still begin up to 12 months prior to the month they apply, known as retroactive coverage. How this looks will depend on whether they are on, or need, dialysis, or require a kidney transplant.
In the event a Medicare patient is on dialysis, their coverage typically begins on the first day of the fourth month of dialysis treatment. Do note, this four-month waiting period starts even if someone hasn’t yet signed up for Medicare.
If someone is covered by an employer group health plan, their coverage will still begin the fourth month of dialysis. As well, the group health plan may cover the first three months of treatment.
Medicare coverage begins as soon as the first month of a regular course of dialysis treatments if all of the following are true:
The patient participates in a home dialysis training program during the first three months of a regular course of dialysis (must be a Medicare-approved facility)
The patient’s doctor expects them to complete home dialysis training, meaning they can perform self dialysis at home
They continue regular course dialysis treatments throughout the waiting period
Medicare coverage for kidney transplants works differently than dialysis. Learn more at this resource. Learn more at this resource.
When Medicare Coverage Ends for ESRD
If a Medicare patient only has Medicare because of permanent kidney failure, Medicare coverage will end:
12 months following the cessation of dialysis treatment
36 months after a kidney transplant
However, coverage can resume again in certain situations. Visit Medicare’s official website to learn more.
How to Sign Up for ESRD Medicare
If a patient is eligible for Medicare based on ESRD and they qualify for Medicare Part A, they can also enroll in Medicare Part B. It is important to note that in order to receive the full ESRD benefits under Medicare, they must sign up for both Medicare Part A and Medicare Part B. Eligible enrollees can do so by visiting their local social security office or by contacting Social Security.
There are two ways to do this: choosing an Original Medicare plan or a Medicare Advantage plan.
Health Services Covered Under ESRD Medicare
If a Medicare beneficiary requires dialysis, the federal Medicare program covers various dialysis services, including:
Inpatient dialysis treatments
Outpatient dialysis treatments outpatient doctor’s services
Home dialysis training
Home dialysis equipment and supplies
Some home support services
The majority of drugs needed for outpatient or home dialysis
Dialysis when traveling within the United States (has to be a Medicare-certified dialysis facility)
Do note, most of the time, Medicare will not pay for transportation to dialysis facilities.
ESRD Medicare Coverage for Prescription Drugs
After someone becomes eligible for ESRD Medicare, they can enroll in a Medicare drug plan during a seven-month period. This seven-month period begins three months prior to the first month they are eligible for Medicare. It will end three months following the first month they’re eligible.
Prescription drug coverage begins at the same time as Medicare coverage. It may also start the first month after a request is sent, whichever date is later.
Finally, Medicare Part B will pay for most of the drugs needed for dialysis, though it won’t cover prescription medication for other health conditions. In this scenario, patients would need to enroll in Medicare Part D, which is prescription drug coverage.
Do Medicare Advantage Plans Cover Dialysis?
Starting in 2021, those with ESRD can enroll in a Medicare Advantage plan. Medicare Advantage plans, also known as Medicare Part C or MA plans, have the same level of coverage as Original Medicare but have different costs and additional benefits.
Do note, MA plans cannot establish cost-sharing for outpatient dialysis immunosuppressive drugs higher than a patient would be paying under Original Medicare.
Finally, ESRD or kidney patients interested in enrolling in an MA plan should consider costs and provider networks before making the switch. They should also ensure their dialysis facility and other health care providers are within a potential new plan’s network.
Does Medigap Help Cover Dialysis?
Medigap can help “fill in the gaps” of traditional Medicare coverage, including services and costs associated with dialysis. However, Medigap is not available to all ESRD patients on Medicare. Learn more at this resource.
Dual Eligibles Program & Dialysis
The Dual Eligibles Program is for patients who qualify for both Medicare and Medicaid coverage. If eligible and enrolled, Medicare will act as the beneficiary’s primary insurance while Medicaid acts as the secondary insurance.
When it comes to dialysis treatment, Medicaid should cover any cost that Medicare does not.
Note: To learn more about Medicaid services and Dual Eligibility, visit this source.
In cases of ESRD, someone will need specific medical interventions, such as regular dialysis or a kidney transplant, in order to survive.
ESRD Medicare works differently than other types of Medicare. This includes when Medicare begins, eligibility, health care costs, overall health coverage, and more.
Visit the Medicare federal government website to learn more, find a Medicare-approved hospital or dialysis center, and more.