Exploring Medicare Coverage for End Stage Renal Disease

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

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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:

1. Your kidneys are no longer functioning

2. You need regular dialysis, or you've had a kidney transplant

In addition, one of the following should apply:

1. You've fulfilled the necessary duration of employment under Social Security, the Railroad Retirement Board (RRB), or as a government employee

2. You receive or qualify for Social Security or Railroad Retirement benefits

3. You are the spouse or child of an individual who meets one of the criteria listed above

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:

1. Dialysis treatments and services:

   1. Inpatient dialysis treatments

   2. Outpatient dialysis treatments

   3. Home dialysis training — instruction for you and the person helping you with your home dialysis treatments

   4. Home dialysis equipment and supplies — dialysis machine, water treatment system, basic recliner, alcohol, wipes, sterile drapes, rubber gloves, and scissors

   5. Certain home support services — such as visits by trained hospital or dialysis facility workers who monitor your home dialysis, help during emergencies, and check your dialysis equipment and water supply

   6. Most drugs for outpatient or home dialysis

   7. Other dialysis-related services and supplies — e.g., lab tests

2. Kidney transplants and transplant-related services:

   1. Kidney registry fee

   2. Tests that evaluate your condition and the condition of potential kidney donors

   3. Inpatient services in a Medicare-certified hospital

   4. The costs of finding the proper kidney for your transplant surgery (if there’s no kidney donor)

   5. The total cost of care for your kidney donor. This includes the following:

      1. Services before, during, and after the surgery

      2. Any inpatient hospital care needed if surgical complications arise

      3. Doctor services during a donor's hospital stay

   6. Doctor services for your kidney transplant surgery — including care before, during, and after surgery

   7. Transplant drugs (i.e., immunosuppressive drugs) after you leave the hospital following a transplant

      1. Note: Coverage lasts for a limited amount of time

   8. Blood — whole or units of packed red blood cells, blood components, and the cost of processing and giving you blood

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:

• Medicare Part B covers transplant drugs and most other drugs needed for dialysis

• Medicare covers immunosuppressant drugs for 36 months after your kidney transplant surgery — but ONLY if you have both A and B

• Parts A and B do NOT cover prescription drugs for other health issues like diabetes or blood pressure

ESRD Drug Coverage: Medicare Part D

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

• Medicare Part D helps with drug costs not covered by Medicare Part B

• If you don't have Medicare Part A at the time of your transplant, you need Part D to cover the costs of your immunosuppressant drugs

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?

• The same services provided by all Medicare Advantage plans

• Additional specialized services for those with chronic conditions (e.g., extra days in the hospital)

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.

• For example, if your dialysis starts in May, your Medicare coverage will begin on August 1st

• Note: If you're enrolled in an employer group health plan, your Medicare coverage still starts during the fourth month of dialysis treatments. Your group health plan may pay for the first three months of dialysis. 

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: 

• You complete a home dialysis training program (offered by a Medicare-certified training facility) during the first three months of treatment

• Your doctor expects you to finish training and be able to manage your dialysis treatments at home

• You maintain a regular course of dialysis throughout the waiting period — i.e., the three-month period before Medicare begins

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:

• 12 months after the month you stop dialysis treatments.

• 36 months after the month you have a kidney transplant.

Your Medicare coverage will resume if:

• You start dialysis again, or you get a kidney transplant within 12 months after the month you stopped getting dialysis

• You start dialysis or get another kidney transplant within 36 months after the month you get a kidney transplant

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:

• Your annual deductible

• A daily hospital coinsurance if your stay exceeds your benefit period

  • Days 1-60: $0 coinsurance for each benefit period

  • Days 61-90: $400 (in 2023) copayment each day

  • Days 91-150: $800 (in 2023) copayment each day while using your 60 lifetime reserve days 

  • After day 150: You pay all costs

• 20%  coinsurance of the Medicare-Approved Amount for doctor services (if your provider accepts Medicare assignments)

Out-patient dialysis costs include:

• Your Part B deductible

• 20% coinsurance for the Medicare-approved amount for all covered dialysis services

Home dialysis costs include:

• Your Part B deductible

• 20% coinsurance for the Medicare-approved amount for all covered dialysis services

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:

• Monthly premium — based on your income

• Annual deductible — $226 for 2023

• 20% of the Medicare-approved amount for your immunosuppressive drugs 

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.

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