Exploring Medicare Coverage for End Stage Renal Disease

Roughly 786,000 people in the U.S. suffer from kidney failure — ESRD.

While long-term treatments make the condition more manageable, they're expensive; ESRD patients often need medical care for years, and these costs add up over time.

Luckily, Medicare covers treatments for qualifying candidates.

Let's take a look at Medicare's ESRD benefits. We'll discuss who's eligible for treatments, what services Medicare covers, and how long coverage lasts.

What Is ESRD?

ESRD (End Stage Renal Disease) — also known as kidney failure — occurs when chronic kidney disease reaches an advanced stage.

Kidney function deteriorates so much that the kidneys can no longer meet the body's needs. To survive, you need either dialysis or a kidney transplant.

Am I Eligible for ESRD Medicare Coverage?

To qualify for ESRD benefits, you must meet the following conditions:

In addition, one of the following should apply:

Note: While ESRD most commonly affects older adults, age doesn't impact your eligibility for Medicare benefits.

What ESRD Services Does Medicare Cover?

ESRD coverage depends on your

specific Medicare plan

. Let's take a look at the services each program provides.

ESRD Services Covered by Original Medicare

Original Medicare covers the following services:

ESRD Drug Coverage: Original Medicare (Parts A and B)

ESRD patients who undergo kidney transplants or dialysis qualify for drug coverage.

Here's what to expect if you have Medicare Part A and Part B:

ESRD Drug Coverage: Medicare Part D

Here's what to expect if you have Medicare Part D:

ESRD Services Covered by Medicare Advantage Plans

A

Medicare Advantage plan

(aka Medicare Part C) covers the same services as

Original Medicare

.

You also have the option to enroll in additional Medicare Advantage programs to get extra benefits — like prescription drugs, vision, hearing and dental coverage. Here's one option:

Special Needs Plan

A

Special Needs Plan

(SNP) is a type of Medicare Advantage Plan for people with specific diseases or characteristics. These plans have custom benefits, health care providers, and medication lists to meet the unique needs of the populations they support.

Specifically, ESRD patients can enroll in C-SNP (Chronic Condition SNP).

What ESRD services does C-SNP provide?

ESRD Services Covered by Medicare Supplement Plans

Medicare Supplement plans, also known as Medigap plans help cover the expenses left by Original Medicare. They may cover a portion or all of your out-of-pocket costs.

(Exact coverage depends on your specific

Medicare Supplement plan

).

How Do I Get ESRD Benefits From Medicare?

First, you need to sign up for Medicare. Visit the nearest Social Security branch or dial 1-800-772-1213. (If you use TTYs, dial 1-800-325-0778).

To get full ESRD benefits, you'll need both Parts A and B of Original Medicare. If you qualify for Medicare Part A, you can also get Part B.

I Enrolled in Medicare Part B Past the Deadline. Will I Have to Pay a Late Fee?

If you're eligible for Medicare due to ESRD, you're exempt from a late enrollment penalty for Medicare Part B.

Already paying a late enrollment fee for Medicare Part B? Don't worry. Once you qualify for ESRD benefits, this penalty discontinues.

When Do My ESRD Medicare Benefits Start?

Medicare provides retroactive coverage. So, if you're eligible for Medicare due to ESRD but delay your enrollment, Medicare may provide coverage up to 12 months before you apply.

However, your exact Medicare coverage start date depends on your ESRD treatments.

Start Dates for Dialysis Treatments

Medicare coverage begins on the first day of the fourth month of your dialysis treatments — even if you haven’t signed up for Medicare yet.

Does Medicare coverage ever begin sooner?

Yes! Coverage can begin as early as the first month of regular dialysis treatments if you meet all of these conditions: 

So, Medicare won’t cover surgery or other preparatory services (e.g., surgery for blood access) before the fourth month. But if you complete home dialysis training, your Medicare coverage starts the month you begin regular dialysis treatments.

In addition, if you already have Medicare due to age or disability, you'll receive coverage for physician-ordered fistula placements and other preparatory services.

Start Dates for Kidney Transplants

Generally, Medicare coverage begins the month you are admitted to a Medicare-certified hospital for a kidney transplant (or transplant-related services).

This rule applies if your transplant occurs within two months of your admission. If your transplant is delayed for more than two months after your hospital admission, Medicare coverage can begin two months before your transplant. 

How Long Do My ESRD Medicare Benefits Last?

If you have Medicare only because of permanent kidney failure, Medicare coverage will end:

Your Medicare coverage will resume if:

How Much Do ESRD Treatments Cost with Medicare?

Medicare covers most ESRD treatment costs. But you'll still have to pay some out-of-pocket expenses. The exact price depends on the type of treatment you get.

In-patient kidney transplant and dialysis costs include:

Out-patient dialysis costs include:

Home dialysis costs include:

If you have Medicare Part A and B, Medicare will cover your immunosuppressant drugs for 36 months after the month of your transplant.

You might have to pay much less if you have a Medicare Advantage or Medicare Supplement plan, as these plans cover most or all of your out-of-pocket expenses.

What Is Part B Immunosuppressant Drug Benefit?

The Immunosuppressant Drug Benefit helps you afford immunosuppressive drugs beyond 36 months if you don’t have other health coverage.

If you sign up, here's what you'll pay:

This new benefit begins on January 1, 2023. To sign up, call the Social Security line at 1-877-465-0355. (TTY users can contact our general line at 1-800-325-0778).

Takeaway

Medicare

covers most of your ESRD treatment costs. You still may have to pay the deductibles, copays, and coinsurance amount. A Medicare Supplement plan can help cover these out-of-pocket expenses.

ESRD Medicare benefits and their coverage limits can be confusing. If you have further questions, feel free to talk to

our experts

at 1-888-376-2028.