ESRD Medicare (End Stage Renal Disease): What to Expect for 2021
If you don’t manage your diabetes or high blood pressure, you may put yourself at risk of end stage renal disease
Reviewed by: Eboni Onayo, Licensed Insurance Agent. Written by: Bryan Strickland.
Key Takeaways
Original Medicare insurance (Parts A and 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). covers most of the treatment you’ll need with end stage renal disease (ESRD), including medical services and supplies in hospitals, doctors’ offices and at home.
Beginning in 2021, individuals with ESRD may be eligible to enroll in Medicare Advantage (Part C)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).. Medicare Advantage replaces Original Medicare and has an annual out-of-pocket limit on Part A and Part B care that can protect you from high costs.
If you are eligible for Medicare because of ESRD but continue with your group health plan, Medicare can help as a secondary payer.
Medicare covers most of the treatment you’ll need with ESRD, including medical services and supplies in hospitals, doctors’ offices, and other healthcare facilities.
The Centers for Disease Control and Prevention estimate that one out of every 500 Americans live with end stage renal disease (ESRD).
What is end stage renal disease? ESRD is the most severe form of chronic kidney disease, and it requires dialysis or a kidney transplant for survival. [1]
Given the severity of and the costliness of ESRD, Medicare offers coverage for the disease regardless of your age.
On This Page
Does Medicare Cover ESRD?
Original Medicare as well as Medicare Advantage (as of 2021) covers end stage renal disease.
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.
Do You Have to Sign Up for Medicare if You Have ESRD?
You need both Parts A and B of Original Medicare to take advantage of the extensive coverage offered by Medicare. Having both Parts A and B also opens up the option to switch to a Medicare Advantage plan, which replaces Original Medicare while providing at least the same coverage as Parts A and B.
One type of Medicare Advantage plan, a C-SNP, is specially designed for people facing certain chronic diseases. [2] C-SNPs are available in some areas of the country. A GoHealth licensed insurance agent can help determine your eligibility.
Is Medicare Primary for ESRD?
If you are eligible for Medicare because of ESRD but continue with your group health plan, Medicare would pay secondary to your primary group health plan insurance during your 30-month coordination period. [3]
- Whether Medicare is your primary or secondary insurance for ESRD, Part B of Original Medicare — commonly known as “medical insurance” — will do much of the heavy lifting in terms of Medicare’s contribution to your costs. Part B will pay 80% of eligible costs after you meet your annual deductible. You will pay 20% coinsurance.
- Part A — commonly known as “hospital insurance” — will pay hospital costs related to ESRD after you pay your benefit period deductible. Unlike Part B, Part A doesn’t have a monthly premium for most people, and the first 60 days in the hospital don’t require coinsurance.
- Medicare Advantage plans cover at least the same costs as Parts A and B.
How Do I Get Medicare for End Stage Renal Disease?
Medicare coverage usually starts on the first day of the fourth month of your dialysis treatments. Still, the waiting period begins even if you haven’t yet signed up for Medicare, and your coverage can be retroactive. For example, if you start dialysis on July 1, your coverage will begin on Oct. 1, even if you don’t sign up for Medicare until Dec. 1.
Medicare coverage can begin the first month of dialysis if you participate in a home dialysis training program offered by a Medicare-certified training facility during the first three months and your doctor expects you to finish training and be able to do your own dialysis treatments. [4]
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.