Medicare Basics: End Stage Renal Disease (ESRD)

checkmark Fact checked Contributing expert: Roseann Birch, insurance consultant; Reviewed by: Leron Moore, Medicare consultant - Updated: Oct 18, 2021

 

Learn about Medicare eligibility, coverage, and costs for ESRD.

What you should know:

  • 1 You may qualify for Medicare coverage under the age of 65 with end-stage renal disease based on kidney function and treatment.
  • 2 You can qualify for ESRD Medicare coverage if you or your spouse meet work requirements and your kidneys have stopped working, you require regular dialysis, or you’ve had a kidney transplant.
  • 3 If you qualify for Medicare based on ESRD, you’ll receive full Medicare coverage, including services beyond those related to kidney failure.
  • 4 ESRD Medicare works with other coverage, such as employer or union group health plans.

Medicare is often thought of as health care coverage for people age 65 and over, but that’s not always the case. Younger people with end-stage renal disease (ESRD) can also qualify for Medicare, regardless of age. ESRD occurs when kidneys permanently stop functioning and require regular, long-term dialysis treatments or a kidney transplant.

You must meet certain requirements to qualify for Medicare based on ESRD, and coverage doesn’t begin right away. You may want additional coverage to help pay for services ESRD Medicare does not cover. If you are still covered by an employer or union group health plan, you should also understand how Medicare works with your group health coverage. Here is what you should know about ESRD Medicare before you enroll.

ESRD Medicare eligibility

If you have ESRD, you may be eligible for Medicare regardless of your age.

“(Medicare) can be a big help for people with ESRD in managing their health and paying for treatment,” says Bryan W. Adams, co-founder and CEO of Integrity Marketing Group.

You qualify for Medicare based on ESRD if your kidneys have stopped working, you require regular dialysis, or have had a kidney transplant.

You or your spouse or dependent child will also need to have worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee. This generally means working and paying Medicare taxes for at least 10 years.

“If you have questions about ESRD eligibility, it’s a good idea to contact your local Social Security office or talk with a licensed Medicare insurance agent,” Adams says. “They can help you find out if you qualify.”

What’s covered by ESRD Medicare?

If you qualify for Medicare based on ESRD, you’ll receive full Medicare coverage, including services beyond those related to kidney failure. ESRD Medicare coverage gives you access to both Medicare Part A, which covers inpatient hospital stays or temporary time at a skilled nursing facility and some home health and hospice care, and Medicare Part B, which helps pay for doctors’ services, outpatient care, medical supplies, and preventive services.

“Because it has a monthly premium, enrolling in Part B is optional,” Adams says. “However, you’ll need both Part A and Part B to receive the full benefits available under Medicare to cover certain dialysis and kidney transplant services.” These benefits can be very valuable to people with ESRD, he says. ESRD Medicare coverage includes:

  • Kidney transplants
  • Hospital inpatient dialysis
  • Outpatient dialysis from Medicare-certified facilities
  • Home dialysis training, equipment and supplies for you or your caregiver
  • Medications related to treatment

Medicare usually does not pay for:

  • Transportation to a dialysis facility
  • Paid dialysis aides to help with home dialysis training
  • Income lost due to home dialysis training
  • A place to stay during treatment
  • Blood or red blood cells for home dialysis treatment unless these are included in a doctors’ services.

You should also be advised that in most cases, Medicare does not provide health care coverage for services outside of the U.S., says Vincent Birardi, a certified financial planner and wealth advisor at Halbert Hargrove. Exceptions to this are if you’re in the U.S. when the medical emergency occurs and a foreign hospital is the nearest hospital that can treat you; if you’re traveling through Canada to a U.S. state by the most direct path and the Canadian hospital is closer than a U.S. hospital; or if a foreign hospital is closer to where you live than the nearest U.S. hospital that can treat your condition.

Medigap may help pay for services received outside the U.S., including dialysis, if your care begins during the first 60 days of your trip and is not covered by Medicare. “Medigap is sold by private insurance companies and is designed to offset costs associated with Medicare deductibles and coinsurance,” Birardi says.

Can I get prescription drug coverage with ESRD Medicare?

Medicare Part B, which you can receive based on ESRD, provides coverage for transplant drugs after you receive a covered kidney transplant as well as many dialysis drugs, but it does not cover prescription medications for other health conditions. To receive help paying for prescriptions unrelated to ESRD, you’ll need Medicare Part D.

If you qualify for ESRD Medicare coverage, you can join a Medicare drug plan during your seven-month enrollment period. This period starts three months before the month you become eligible for Medicare and ends three months after that month.

Can I get Medicare Advantage with ESRD?

People with ESRD have another Medicare coverage option beyond just Original Medicare. “Individuals that are on Medicare with ESRD can now enroll in a Medicare Advantage Plan (MA, or MA-PD, if the plan includes prescription drug coverage), the same as any other Medicare beneficiary,” says John Norce, president of Medicare assistance firm MedicarePortal. Medicare Advantage Plans provide all-in-one coverage through a private company that contracts with Medicare.

The benefit of MA and MA-PD access for newly eligible ESRD beneficiaries is a reduction in monthly premiums as most plans are priced lower than Medicare supplement plans, Norce says. You also get access to ancillary benefits, such as dental, vision and hearing, as well as gym memberships, transportation and over-the-counter drugs, he says. Not all plans provide these ancillary benefits and each plan can charge different out-of-pocket costs and rules for how you get services. They can also be tailored to provide customized benefits to treat specific conditions for certain chronically-ill enrollees.

“For many, this could be an opportunity to access new benefits and improve their overall health,” Norce says. “The one downfall can be network limitations and this can only be determined by doing a provider search for the plans in your service area.”

Since most MA and MA-PD plans require you to use in-network healthcare providers, you’ll want to ensure the plan you choose has providers in your area that offer the services you need, such as dialysis treatment, and are someone you would want to see.

When does ESRD Medicare coverage start and end?

Your ESRD Medicare coverage start date depends on your condition. If you’re on dialysis, coverage usually begins the first day of the fourth month of your dialysis treatments, regardless of when you sign up or if you’re still covered by an employer health plan. If you participate in a home dialysis training program through a Medicare-certified training facility during the first three months of your dialysis treatments, you can avoid this four-month waiting period. In this case, your ESRD Medicare coverage can begin the first month of your dialysis treatments. Your coverage can also begin in your first month if your doctor says you’ll finish training and be able to perform your own dialysis treatments.

Medicare based on ESRD can be applied retroactively up to 12 months before the month you apply. For instance, if you become eligible for ESRD Medicare in March but don’t sign up for coverage until December, your coverage would start in March. It’s important to note that this retroactive coverage won’t include surgery or other services to prepare for dialysis unless you complete home dialysis training and your Medicare coverage begins in your first month of treatments. That said, if you’re already receiving Medicare, your coverage will include preparatory services before you begin dialysis.

If you’re getting a kidney transplant, your ESRD Medicare coverage could begin the month you’re admitted to a Medicare-certified hospital for your transplant, provided the transplant occurs within the next two months. For transplants that are delayed by more than two months after you are admitted to the hospital, Medicare coverage can begin two months before your transplant occurs.

ESRD Medicare ends 12 months after the month you stop dialysis or 36 months after your kidney transplant. Coverage can resume if you start dialysis again, get a kidney transplant within 12 months of when you stopped dialysis or get another kidney transplant within 36 months of your previous kidney transplant.

“As you can see, the exact timing of Medicare ESRD coverage and eligibility can depend on a number of different factors,” Adams says. “If you have specific questions about your personal situation or that of a loved one, you can visit the official Medicare website at Medicare.gov to learn more or talk with a licensed Medicare insurance agent.”

How much does medicare with ESRD cost?

You’ll receive premium-free Medicare Part A if you qualify for Medicare coverage based on ESRD. Medicare Part B has a premium, which is either deducted from your Social Security or RRB benefits or billed to you. In 2021, the standard Part B premium, which most people pay, was just under $150. People with modified adjusted gross incomes above a certain amount will also pay an Income Related Monthly Adjustment Amount (IRMAA) that is added to your premium. Part B premiums for people with IRMAAs can be up to $500 in 2021.

The Part B deductible in 2021 is $203. After you reach this amount in payments, you’ll generally only pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy and durable medical equipment.

ESRD can absolve you of the late enrollment penalty levied on people who don’t sign up for Medicare Part B on time. If you’re already enrolled in Medicare when you become ESRD eligible and have been paying a Part B late enrollment penalty, the penalty will stop when you become ESRD Medicare eligible. You’ll need to contact your local Social Security office to re-enroll in medicare based on ESRD.

How to enroll in Medicare with ESRD

If you’re eligible for Medicare due to ESRD, you can enroll in Medicare Part A and Part B online or through your local Social Security office when they reopen.  Social Security Administration offices are currently closed to walk-in clients due to COVID-19. You may be able to make an in-person appointment if your case cannot be handled easily on the phone.The Medicare hotline is still available to answer questions at 1-800-633-4227.

The online application process usually does not require any documentation or signatures and takes only 10 minutes. Be prepared to provide your date and place of birth; Medicaid number and start and end dates, if applicable; Permanent Residence Card number if you are not a U.S. citizen and the start and end dates for your current health insurance through your or your spouse’s employer. You can enroll in Medicare because of ESRD even if you are still covered by an employer or union group health plan. More details on how ESRD Medicare works with other coverage options is provided below.

When you enroll, you’ll also have the option of choosing a Medicare Advantage Plan and stand-alone Part D coverage or a MA-PD plan. You’ll have the option to change your plan elections each year.

How does Medicare work with other coverage options?

Since ESRD Medicare does not start right away, you may want to keep your employer or union group health plan, which can help pay for treatments during the three month waiting period before ESRD Medicare coverage begins.

Once you become eligible for ESRD Medicare, which usually occurs in your fourth month of dialysis, there will be a 30-month “coordination period” when your employer or union group health plan continues to pay your medical bills. This coordination period begins the first month you become eligible for ESRD Medicare, even if you haven’t signed up for Medicare yet.

During the coordination period, your group health plan pays first and Medicare pays second. This means that if your group health plan doesn’t pay all of your health care bills during this time, Medicare may step in to cover some of the remaining costs. This may even include help paying your group health plan deductible, copayment or coinsurance. At the end of the coordination period, Medicare will pay first for all services covered by your plan and your group health plan may step in to help pay remaining costs.

If your group health plan covers most or all of your services, you may want to delay enrolling in Medicare until the 30-month coordination period is over. In this way, you won’t have to pay the Part B premium that you don’t need. You won’t incur a penalty premium for delaying Part B coverage in such a situation. If your group health plans stop or are decreased, you should enroll in Medicare as soon as possible.

There will be a new 30-month coordination period each time you enroll in Medicare due to ESRD even if you don’t have the three-month waiting period for Medicare to begin. For example, if you have a kidney transplant that works for 36 months and you don’t turn 65 during that time period, your medicare coverage will end. If you then start dialysis again later and re-enroll in Medicare, your coverage will begin immediately, however there will still be a new 30-month coordination period if you are still on a group health plan.

Tell your health care provider if you have employer or union group health coverage to ensure the services are billed correctly.
If you haven’t enrolled in Medicare yet, you could also get a Health Insurance Marketplace plan instead, which may provide tax credits or reduced cost-sharing options. Many states have agencies and kidney programs to help with the health care costs Medicare doesn’t cover. Contact your State Health Insurance Assistance Program (SHIP) to learn more about your state’s coverage options.

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.