If you’ve been diagnosed with end-stage renal disease (ESRD), it can seem like the sky is falling around you. As your physician covers the different treatments, you start seeing the dollars add up. How could you possibly afford the support care, the dialysis, or even a transplant? Through the haze you hear it — Medicare may also help you cover these costs.
If you’re eligible, Medicare may be able to help you afford your treatment for ESRD, regardless of your age. Today, we’re going to look beyond the scary name to help you know what ESRD is and how Medicare can help you cover your needs.
What is End-Stage Renal Disease
End-stage renal disease, or end-stage kidney disease, is when a chronic kidney disease advances to the stage where your kidneys no longer function properly. When they work normally, your kidneys take waste and extra liquid in the body and filter them out of your system. If this function breaks down, it can leave a dangerous amount of waste, liquid, and electrolytes behind. If left untreated, this usually leads to death.
Symptoms can include an inability or decrease in how often you urinate, headaches, loss of appetite or unexplained weight loss, nausea and vomiting, or changes in skin color. Causes of ESRD can include type 1 or 2 diabetes, high blood pressure, a prolonged UT blockage, or one of a number of kidney diseases or infections.
Causes of ESRD can include type 1 or 2 diabetes, high blood pressure, a prolonged UT blockage, or one of a number of kidney diseases or infections.
Treatment options are generally more limited, usually dialysis or a kidney transplant. Dialysis is a form of treatment that does the job of the kidney for your body. It can be done inside the body (peritoneal dialysis) or externally (hemodialysis).
How Does ESRD Affect Medicare?
If you have ESRD, there is a very good chance that you’re eligible for Medicare, regardless of your age. Essentially, if you’re otherwise eligible for Medicare, except for the age aspect, and have ESRD, you can enroll. Specifically, in order to be eligible, you must fit the following circumstances:
- Your kidneys are unable to function properly
- You require dialysis or have gotten a kidney transplant
- And, one of the following:
- You’ve worked the qualifying amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee
- You’re eligible or receiving Social Security or RRB benefits
- You’re the spouse or dependent of someone who meets these circumstances
If you’re enrolled in a group health plan through work, the Consolidated Omnibus Budget Reconciliation Act (COBRA), or a retirement plan, Medicare acts as a secondary payer during a coordination period of 30 months — even if it’s stated otherwise in the group health plan. The benefits of the group health plan may not differentiate services for those with ESRD, including higher fees, benefit limits, or termination of coverage.
Between Parts A and B, most of your needs should be covered.
If you’re eligible, you can enroll in Original Medicare at your local Social Security office. Between Parts A and B, most of your needs should be covered. For example, Part A would cover inpatient services once you’ve met the Part A deductible ($1,600 in 2023). This includes inpatient dialysis treatments or even a kidney transplant. Part A will also cover your hospital stay, though the days over your benefit period may be covered by a hospital coinsurance. Part B, on the other hand, covers doctors’ fees, like those for a transplant surgeon, or outpatient services. These may be outpatient or at-home dialysis services. You may need to pay a coinsurance, depending on the service.
Finally, Part B will cover your post-transplant immunodepressant drugs while you’re covered by Medicare. You’ll need these drugs for the rest of your life. To qualify for coverage, you’ll need to have had Part A when you received the transplant, have Part B when filling the prescription, and you’re only eligible for Medicare due to ESRD. If not, Part D may be able to cover this medication.
Finally, Part B will cover your post-transplant immunodepressant drugs while you’re covered by Medicare. If not, Part D may be able to cover this medication.
You may also be eligible to join a Medicare Advantage plan. Prior to 2021, Medicare Advantage options for those with ESRD were limited to specific situations, like if you were already enrolled in a Medicare Advantage plan when you developed ESRD. Since 2021, beneficiaries with ESRD have qualified for Medicare Advantage, opening up access to a wide number of plans and coverage options.
When Does My Medicare Coverage Begin?
The coverage waiting period begins whether you’re enrolled in Medicare or not, up to 12 months prior.
Your ESRD Medicare coverage begins on the first day of your fourth month of dialysis treatments. This waiting period begins whether you’re enrolled in Medicare or not, up to 12 months prior. This means if you’ve received four months of dialysis treatment already, your coverage can start as early as the first day of the next month! If you fulfill all the following circumstances, you may be able to start as early as your first month of dialysis:
- You took a home dialysis program through a Medicare-certified facility
- Your doctor expects you to finish the program and be able to do your own dialysis treatments
- Your regular course of dialysis is maintained through the standard waiting period that would have applied
Your Medicare coverage ends if you go 12 months without dialysis treatment or 36 months have passed since the month after your kidney transplant. Your coverage can be extended if you receive dialysis or a kidney transplant with 12 months of stopping dialysis or 36 months of getting a kidney transplant.
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End-stage renal disease can be scary and expensive. It’s a daily process just to make sure that your body is functioning properly. Through Medicare, no matter what your age is, assistance is available.