ESRD Medicare (End-stage Renal Disease): What to Expect
Key Takeaways
Original Medicare (Parts A and B) 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.
Individuals with ESRD are now eligible to enroll in Medicare Advantage (Part C) . 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.
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.
Given the severity of and the costliness of ESRD, Medicare offers coverage for the disease regardless of your age.
Does Medicare Cover ESRD?
Original Medicare as well as Medicare Advantage 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. 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 become the secondary payer to your primary group health plan insurance during your 30-month coordination period.
- Whether Medicare is your primary or secondary insurance for ESRD, Part B of Original Medicare — which provides medical insurance — will do much of the heavy lifting. Part B will pay 80% of eligible costs after you meet your annual deductible. You will pay 20% coinsurance.
- Part A is hospital insurance, which will cover 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 October 1, even if you don’t sign up for Medicare until December 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.
