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Medicare and End Stage Renal Disease (ESRD) Explained: What to Expect for 2021

For ESRD patients, look no further than 2021 to enroll in Medicare Advantage or Original Medicare plans.

Reviewed by: Selah Lee, Licensed Insurance Agent. Written by: Andrew Hall.

Key Takeaways

  • Beginning January 1, 2021, individuals with ESRD may be eligible to enroll in Medicare Advantage (MA)Medicare Advantage is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). plans.

  • Medicare Advantage Plans have annual out-of-pocket limits on your Part AMedicare Part A, also called "hospital insurance," covers the care you receive while admitted to the hospital, skilled nursing facility, or other inpatient services. Medicare Part A is one of the pain parts of Original Medicare. and Part BMedicare Part B is the portion of Medicare that covers your medical expenses. Sometimes called "medical insurance," Part B helps pay for the Medicare-approved services you receive. care, which can protect you from very high costs.

  • If you have chronic kidney disease and need dialysis, you may be eligible for Original Medicare insurance (Part A and Part B)Original Medicare (Parts A and B) is fee-for-service health insurance available to all Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance)..

  • Medicare covers most of the treatment you’ll need with ESRD, including medical services and supplies in hospitals, doctors’ offices, and other healthcare facilities.

African Americans holding hands in anticipation of medical information.

Can I enroll in Medicare Advantage with ESRD?

Yes. Beginning January 1, 2021, individuals with ESRD can enroll in Medicare Advantage (MA) plans. Before 2021, beneficiaries typically could not enroll in Medicare Advantage.

What’s the difference between Medicare Advantage and Original Medicare for ESRD?

Medicare Advantage plans must cover the same services as Original Medicare but may have different costs and restrictions. However, Medicare Advantage plans cannot charge more than Original Medicare for outpatient dialysis or immunosuppressant drugs.

Medicare Advantage plans have annual out-of-pocket limits on your Part A and Part B care. These limits may be high but can help protect you if your healthcare costs are high.

How many Medicare Advantage plans enroll people with ESRD in 2020?

ESRD affects more than 500,000 Medicare beneficiaries. Currently, Medicare Advantage covers 130,000 people with ESRD (25% of Medicare beneficiaries). These beneficiaries were eligible before 2021 because they either developed ESRD after enrolling or were grandfathered in through a job-based plan. The Centers for Medicare and Medicaid Services (CMS) estimates an additional 83,000 people with ESRD will enroll in Medicare Advantage by 2026. [1]

According to studies from CMS, [2] Medicare Advantage beneficiaries experienced 12.4% shorter average lengths of stay in medical facilities compared with traditional fee-for-service Medicare.

Can you get Original Medicare with End Stage Renal Disease (ERSD)?

If you receive a diagnosis of end-stage renal failure, you need to learn your care options quickly. You can get Medicare no matter how old you are if all of these apply:

  • You’re diagnosed with kidney failure.
  • You need regular dialysis or have had a kidney transplant.

And, one of these applies to you:

  • You’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee.
  • You’re already getting or are eligible for Social Security or Railroad Retirement benefits.
  • You’re the spouse or dependent child of a person who meets either of the requirements listed above.

Medicare is a federally funded health insurance program for Americans over age 65 and people who have been deemed disabled. In 1972, people requiring dialysis became newly entitled to this health benefit. Today, if you have chronic kidney disease (CKD) and need dialysis, you may be eligible for Medicare insurance.

Do you have to sign up for Original Medicare if you have ESRD?

If you are under 65, you may be eligible for Medicare benefits if diagnosed with ESRD. After you enroll for Medicare health benefits, your treatment determines the date your services become active.

Part A (Hospital Insurance) – Covers all inpatient services
Part B (Medical Insurance) – Covers all clinical outpatient services

Patients with ESRD who begin home dialysis (peritoneal dialysis or home hemodialysis) have an additional advantage regarding Medicare coverage. If you choose a home dialysis therapy, you can qualify for Medicare immediately upon dialysis initiation.

What costs do Medicare cover when I have ESRD?

Medicare covers certain medical services and supplies in hospitals, doctors’ offices and other health care settings. When you need dialysis, Medicare will cover the cost of dialysis treatments. Dialysis patients need to go to a treatment facility where Medicare covers dialysis.

What’s your out-of-pocket?

Patients pay 20% coinsurance, also called cost-share, for dialysis treatment in a dialysis center. Outpatient doctors’ visits will also cost 20% coinsurance. The same amount also relates to home dialysis training, home dialysis equipment, and supplies. All of these are applicable if you have Medicare Part B. If you are admitted to a hospital for dialysis, your Part A insurance will cover those costs.

FAQs

Will Medicare cover my kidney transplant?

Yes, Medicare covers kidney transplants as long as the surgery is performed at a Medicare-approved hospital. Medicare will cover you for 36 months after the month you receive a kidney transplant. After that time, you will not be covered by Medicare to pay for your immunosuppressive drugs.

Do I have to pay for Medicare Part A and Part B?

You will not have to pay for Medicare Part A if you or your spouse worked and paid Medicare taxes for at least 10 years. If you or your spouse did not pay Medicare taxes while employed and are age 65 or older, you might be able to buy Part A.

People on dialysis at any age will pay a standard monthly Part B premium and likely pay for Part A. Some people will pay a higher premium based on their income.

What is Medigap, and can I get this policy if I have ESRD?

Medigap is health insurance that fills in the “gaps” that Original Medicare won’t cover. If Original Medicare does not fully cover a specific health care cost, Medigap can usually pay for what was not covered.

Not all private insurers will sell Medigap to people under age 65, even if they have end stage renal disease. Medigap rules vary from state to state, and if you are under 65 and receive this policy, you may pay more because of your age.

Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. Also, you will have to pay a premium to the Medigap insurance company.

What’s Next?