Does Medicare Cover ESRD and Kidney Failure?

ESRD patients are eligible for Medicare coverage. To find available Medicare plans near you, call our experienced, licensed agents today at (800) 950-0608.

ESRD and Kidney Failure Are Hard Roads to Navigate Without Some Assistance

End Stage Renal Disease (ESRD) is an extremely debilitating disease that has become more common now than ever. More than 200,000 cases of kidney disease, whether acute or chronic, are diagnosed in the United States every year. This makes it perhaps one of the most common comorbidities of certain chronic conditions, including:

• Diabetes
• Hypertension
• Heart disease

You’re also more susceptible to developing kidney disease if you have a family history of kidney failure.

When an individual is diagnosed with ESRD, also known as kidney failure, the grief of the diagnosis can be immense. Not only are you wondering how you’ll be able to cope with the disease, you’re likely also wondering how you’ll be able to pay for the expensive treatments and medications that come with it. In fact, two of the most common questions we receive regarding Medicare eligibility are:

• “Does Medicare cover kidney failure?”
• “Does Medicare cover dialysis?”

Fortunately, all types of Medicare plans will cover forms of treatment and medications for ESRD and kidney failure. They do, however, come with their own limitations. Let’s take a look at the options available for Medicare and End Stage Renal Failure.

If You Suffer from ESRD, You Are Eligible For Medicare Regardless of Your Age

Many individuals with ESRD consider Medicare coverage, but they worry about being able to enroll if they’re under the required enrollment age of 65. If you suffer from ESRD, or the end stages of renal failure, you can actually enroll in Medicare regardless of your age.

In order to enroll, you still have to meet certain requirements. The requirements for being able to enroll include:

• Your kidneys are no longer functional
• You need regular dialysis
• You’ve had a kidney transplant
• One or more of the following 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 currently receiving or are eligible for Social Security or RRB benefits
  • You’re the spouse or dependent child of a person who meets either of the requirements listed above

If you qualify for Medicare Part A after meeting the requirements, you’re also eligible to enroll in Medicare Part B. It’s a good idea to enroll in both Part A and Part B in order to get full benefits for the dialysis and kidney transplant services that are covered by Medicare.

It’s also important to note that if you are approved for Medicare because of ESRD, you can sign up for Part B at any time without incurring the late enrollment penalty. If you currently receive Medicare based on age or disability and you’re paying a Part B late enrollment penalty, that penalty stops when you become eligible for Medicare based on ESRD.

I’ve Applied - When Will My Coverage Start?

Eligibility for Medicare coverage based on ESRD is a little different from Medicare coverage based on age or other disabilities. In many cases, the coverage may start up to 12 months before the month that you actually apply if you do not apply right away. This is known as retroactive coverage. For instance, if you’re eligible for Medicare based on ESRD in June, but you hold off on signing up until December, your coverage will start in June.

If you’re on dialysis, your coverage won’t start right away. Medicare coverage for kidney failure patients on dialysis doesn’t start until the first day of the fourth month of your treatments. This four-month waiting period starts even if you haven’t signed up for Medicare.

There are some instances when Medicare coverage for ESRD can start as early as the first month of your dialysis treatments. These instances include:

• Participation in a home dialysis training program offered by a Medicare-certified training facility during the first 3 months of your dialysis treatments.
• Your doctor expects you to finish training and to be able to do your own dialysis treatments at home.
• You maintain a regular course of dialysis throughout the waiting period that would otherwise apply.

If you’re in need of a kidney transplant, your coverage may begin the month you’re admitted to a Medicare-certified hospital for the procedure. This will only happen if your kidney transplant is taking place within the same months or the next two months. If your transplant happens to be delayed more than two months before your hospital admission, your Medicare coverage may still begin two months before your transplant.

Medicare Coverage Based on Kidney Failure is Not Always Permanent

If your sole reason for Medicare eligibility was kidney failure, it’s important to know that your coverage will eventually come to an end. If you’re only eligible for Medicare coverage as a result of kidney failure, your coverage will end:

• 12 months after the month you stop dialysis treatments.
• 36 months after the month of your kidney transplant procedure.

Your coverage may resume if you start getting dialysis again, or you receive a kidney transplant within a year after the month your dialysis treatments stopped. It may also resume if you start dialysis or get another kidney transplant within three years after the month you receive a kidney transplant.

What Treatments and Supplies Will Medicare Cover for ESRD?

Original Medicare will pay for a variety of treatments and supplies needed to treat ESRD. This includes a limited amount of prescription medications that need to be taken during dialysis or after a kidney transplant procedure.

If you are on ESRD dialysis, Original Medicare will cover the following:

PART A:

• Inpatient dialysis treatments*

PART B:

• Outpatient ESRD dialysis treatments & doctor’s services**
• Home dialysis training – this includes instruction for you and the person who will help you each day with dialysis
• Home dialysis equipment and supplies
• Certain home support services, including check-ins from trained hospital or dialysis facility workers to check on your home dialysis
• Certain prescription drugs for outpatient or home dialysis
• Other services and supplies, such as lab tests, that are part of dialysis

*Part A will only cover inpatient dialysis if you’ve been admitted to a hospital for special care.

**Outpatient dialysis treatments must take place in your home or in a Medicare-certified dialysis facility to qualify for coverage.

Original Medicare will not cover any of the following related to dialysis treatments:

• Paid dialysis aides
• Lost pay for you or the person who helps you during home dialysis training
• Living accommodations during treatment
• Blood or packed red blood cells***

***These may be covered for home dialysis if they’re part of a doctor’s service.

If you’re about to receive a kidney transplant, Original Medicare covers the following:

PART A:

• Inpatient services in a Medicare-certified hospital
• Kidney registry fees
• Tests to evaluate your condition and the condition of potential donors
• The costs of finding the proper kidney for your procedure
• The full cost of care for your kidney donor
• Additional inpatient care for your donor in case post-surgery issues may arise

PART B:

• Doctors’ services for kidney transplant surgery
• Doctors’ services for your kidney donor during their hospital stay
• Transplant medications+

+Part B will only cover these medications for a limited time after you leave the hospital following a kidney transplant procedure.

PARTS A AND B:

• Blood

While Part B will cover transplant medications, there are certain conditions to meet before you can qualify for that coverage. The conditions that you’ll have to meet are as follows:

• You were already enrolled in Medicare Part A at the time of your transplant
• Your transplant surgery happened at a Medicare-certified facility

Even if you qualify for the limited transplant medication coverage under Part B, you’ll lose that coverage if you’re only on Medicare for kidney failure coverage. Your coverage will end three years after the month that your transplant procedure takes place. However, Medicare will continue to pay for your transplant medications without a time limit if you meet one of the following conditions:

• You were already eligible for Medicare because of age or disability before being diagnosed with ESRD
• You became eligible for Medicare because of age or disability after getting a transplant that Medicare paid for.
• You had private insurance that paid primary to your Part A coverage.

How Can I Get Coverage for the Things that Original Medicare Will Not Cover?

Original Medicare will cover many of the treatments related to ESRD, but as with anything, that coverage has its limits. For instance, while Original Medicare may cover many of the medications you need for dialysis or for post-transplant treatment, it will not cover all of them. Nor will Original Medicare cover all of your transports to and from dialysis treatments.

Medicare Part C, or Medicare Advantage, can be a major help if you need more assistance with paying for treatments, procedures, and supplies. A Medicare Part D Prescription Drug plan can help you get all of the crucial medications that you need to manage ESRD, aid dialysis, and help your body keep your new kidney after your transplant. In some cases, you may see these plans bundled together.

The providers of Medicare Advantage and Prescription Drug plans are authorized by the federal government to do so, but they are actually private plans. This means that they may come with few of the caveats or restrictions that Original Medicare plans do, which gives you broader access to coverage for important treatments.

Medicare Can Help You Better Navigate the Tough Road that Comes With ESRD

Treatment options for kidney failure can be expensive. Enrolling in Medicare can help you easily mitigate the costs of treatments and procedures, including dialysis and transplants. As always, it’s important to choose a plan that works best for your needs and budget. With the right plan, the cost of managing ESRD becomes manageable.