Does Medicare Cover End-Stage Renal Disease?

End-stage renal disease (ESRD) is total and permanent kidney failure that can only be treated with dialysis or a kidney transplant, according to the National Institutes of Health. Medicare may cover most of the costs for these treatments, but you will still be responsible for some costs.

ESRD is the final stage of chronic kidney disease (CKD), which includes any condition that causes reduced kidney function over time. About 14% of Americans have some degree of CKD, and roughly 21,000 cases of CKD advance to end-stage renal disease every year in the United States.

There are more than 661,000 Americans who live with kidney failure, according to the NIH. Of these, 468,000 are on dialysis and another 193,000 have functional kidney transplants. But the incidence of ESRD has been declining since its peak in 2006.

Your risk of developing ESRD can depend on your race or ethnicity. Compared to whites, ESRD is 3.7 times more prevalent among African Americans, 1.4 times greater among Asian Americans and 1.4 times greater for Native Americans.

If you develop ESRD, your kidneys are no longer able to adequately filter impurities and toxins out of your blood on their own and you will need dialysis to do it for them.

While dialysis does the job your kidneys can no longer do, it will not cure your kidney disease. You will need to have dialysis treatments for the rest of your life unless you have a kidney transplant.

Dialysis can be done in a hospital, an off-site dialysis center or in your home. Your doctor will help you decide the best place for your dialysis treatments.

The decision will depend on your medical condition and your wishes. You should also consider what Medicare or other insurance will cover.
There are two types of dialysis — hemodialysis and peritoneal dialysis.

In hemodialysis, a doctor performs minor surgery to create an access point on your arm and leg. This is done by altering blood vessels or implanting a catheter. This allows your blood to flow through an artificial kidney outside your body when you receive your regular dialysis treatments.

In peritoneal dialysis, your blood is cleaned inside your body by exchanging fluids through a bag or through a machine. Again, a doctor will have to make an access point using a catheter.

No matter how old you are, if you are diagnosed with ESRD, you can get Medicare to help cover your treatment costs if you meet certain criteria.

Medicare will cover ESRD at any age under one of three conditions: if your kidneys no longer work (ESRD diagnoses), if you require regular dialysis treatment or if you had — or need — a kidney transplant.

If you enroll in Medicare only after you’ve been diagnosed with ESRD, Medicare coverage will usually start in the fourth month of your dialysis treatment.

If you have insurance through your job, retiree or COBRA coverage when you’re diagnosed with ESRD, you don’t have to sign up for Medicare right away. Any of these coverages will remain as your primary coverage for the first 30 months of your treatment.

This 30-month coordination period begins when your eligibility for Medicare ESRD coverage starts. So, if you start dialysis, your Medicare eligibility starts in the fourth month of treatment and your Medicare coverage will start within the same month.

Enrolling in Medicare right away may still save you money. Dialysis is expensive and having Medicare share the costs with your private insurance plan may reduce your out-of-pocket costs.

If you become eligible for Medicare because of ESRD, you can enroll in Medicare Part A hospital insurance and Part B medical insurance. These two parts are collectively called Original Medicare.

If you qualify for Part A, you also qualify for Part B, but you can choose whether you take Part B. To receive full Medicare benefits for dialysis, you will need both parts.

Medicare beneficiaries who already pay a late enrollment penalty for Part B will have the fee removed when applying for ESRD coverage.

Original Medicare does not cover all the prescription drugs you may need after you’re diagnosed with ESRD. But you will be able to enroll in a Medicare Part D prescription drug plan to help with those medication costs.

You will have seven months to sign up for Medicare once you first become eligible for ESRD coverage. The period begins three months before you are eligible, the month you become eligible and continues through the next three months after that.

Once you sign up, your Part D prescription drug coverage begins at either the same time as your Original Medicare coverage begins or the first month after you request Part D coverage, whichever comes last.

Medicare Part B will cover transplant drugs and most medications you need for dialysis treatment once you’ve enrolled in Medicare coverage for ESRD. But you’ll need a Part D prescription drug plan to help cover costs of the prescription drugs you may require for other conditions, such as high blood pressure or diabetes.

Medicare covers most ESRD treatment services. However, you will still have to pay your out-of-pocket share of premiums, deductibles and coinsurance as you would with other Medicare-covered services. You can review these Medicare costs to budget accordingly.

You should be aware of limits on what Medicare will cover. For instance, Medicare does not cover any preparational surgery or other medical services if your coverage has not started.

Ask your doctor about whether services are covered or use Medicare’s coverage tool to see if your product, service or test is covered.

Medicare eligibility for ESRD works differently than other types of Medicare eligibility. For example, you can enroll before you are 65, and unlike typical Medicare, ESRD coverage is retroactive.

Medicare coverage for ESRD ends either 12 months after the month you stop dialysis treatments or 36 months after the month in which you have a kidney transplant.

Most end-stage renal disease coverage is delivered through Original Medicare or in coordinated coverage with employer-related health care insurance, including retiree and COBRA coverage. But there are other options.

Medicare supplemental insurance, also known as Medigap, can help cover the cost of Medicare deductibles and copayments for ESRD treatments, services and supplies.

However, not all states require insurers to offer private Medigap insurance to people with ESRD if they are under 65. Most patients who develop ESRD are younger than 65, according to the National Kidney Fund.

The fund may be able to help with financial assistance for your Medigap premium payments if you do enroll in a Medigap plan due to ESRD and if you meet certain financial need requirements.

Medicaid is another option that may be able to help some people on Medicare cover out-of-pocket expenses for ESRD. But you must first meet dual eligibility requirements for both programs. So, you must show that you have limited income and financial resources.

Dual eligibility rules vary from state to state, and not all low-income Medicare beneficiaries may qualify for Medicaid in their state.

If you are a veteran, the U.S. Department of Veterans Affairs offers several VA benefits, including transplant services for eligible veterans.

VA benefits offer dialysis for chronic kidney disease even if the underlying cause is not service related. The VA also covers certain home dialysis costs and certain medical care in non-VA facilities in your community.

The VA may cover travel costs for your beneficiaries if you travel to a VA facility for dialysis or other VA health care services.

A Medicare Advantage plan may not be a viable option. In most cases, you cannot enroll in a plan — such as an HMO or PPO — after you develop ESRD but have not had a kidney transplant.

You may be able to join a Medicare Special needs plan for ESRD if one’s available where you live. These are specific types of Medicare Advantage plans for people with severe medical conditions who are eligible for Medicare.

You may also be able to enroll if you are still receiving health insurance through a company that also offers a Medicare Advantage plan. But you must buy the Medicare Advantage plan through that particular company.

Once you have had a successful kidney transplant, you may be eligible to enroll in a Medicare Advantage plan.