End-Stage Renal Disease (ESRD) Medicare

Medicare will cover treatment for End-Stage Renal Disease (ESRD). Patients with ESRD will experience permanent kidney failure which may require dialysis or a kidney transplant. Medicare ESRD coverage can help you with benefits that pay for a variety of related healthcare services. However, those with ESRD may not qualify for all Medicare insurance plans because of this disease.

What is ESRD Coverage Through Medicare?

ESRD Medicare coverage helps seniors and even those under 65 who qualify pay for the medical expenses related to end-stage renal disease. Treatment can include in-home dialysis, outpatient dialysis, and more. You must have permanent kidney failure requiring a kidney transplant or dialysis to qualify for Medicare coverage.

It’s important to note a few additional things about ESRD and Medicare. These include the waiting period, eligibility, and plan options:

• You can obtain Medicare coverage under the age of 65 if a doctor diagnoses you with End-Stage Renal Disease. However, you must have enough work history to qualify for Social Security Disability Insurance (SSDI) or be the child or spouse of someone with enough work history to qualify.
• Medicare covers the treatment of End-Stage Renal Disease, including dialysis and a kidney transplant, but you must have permanent kidney failure requiring a kidney transplant or dialysis.

When Does a Person Become Eligible for Medicare with ESRD?

People who are eligible for Medicare solely due to their ESRD diagnosis do not face a waiting period before they can apply for coverage. Instead, ESRD Medicare eligibility begins when a physician prescribes a regular course of dialysis or a kidney transplant necessary for the patient to stay alive at their stage of kidney failure.

Yet, once the patient enrolls, they may face a waiting period before their ESRD Medicare coverage begins. Typically, Medicare coverage for an eligible ESRD patient will begin on the first day of the third month following the month when they start their regular dialysis.

However, Medicare sometimes waives the three-month waiting period. Medicare ESRD patients may receive their coverage sooner if they:

• Have a kidney transplant that falls within those three months
• Partake in a self-dialysis training program

How Do I Enroll in ESRD Medicare?

Enrolling in Medicare with ESRD will require you to contact your local Social Security office. Your doctor will send forms to Social Security to verify that you have end-stage renal disease and to show your treatment plan.

Those with employer coverage don’t need to enroll in Medicare immediately. Your employer plan will cover your dialysis treatment for 30 months before Medicare automatically becomes your primary insurance. You may be able to keep your employer coverage and use it as secondary insurance to Medicare.

If you get your insurance through the Marketplace, you can sign up for Medicare. However, you can’t have both Medicare and Marketplace insurance. Those who don’t enroll in Medicare when their kidneys fail will incur penalties when they do enroll.

Why is End-Stage Renal Disease Covered by Medicare?

Those suffering from end-stage renal disease contend with failing kidneys and need dialysis or a kidney transplant to live. In October 1972, Section 299I of Public Law 92-603 was signed by President Richard Nixon allowing Medicare to cover the high cost of care for those suffering from ESRD.

When Does Medicare Become Primary for ESRD?

Medicare is primary unless you’re in the first 30 months of Medicare for the condition and you have employer group coverage. There is a four-month waiting period that begins for beneficiaries, even if you have yet signed up for Medicare. Your coverage most commonly starts on the first day of the third month of your dialysis treatments.

Can I Get a Medicare Supplement if I Have ESRD?

A Medicare Supplement (Medigap) plan may still be available to those with ESRD. However, this doesn’t mean that the plan you want will accept you as a policyholder. If you are diagnosed with ESRD before you turn 65, you may have to wait until your Open Enrollment at 65 to sign up.

Additionally, enrolling in Medigap under 65 has more to do with state-specific rules than ESRD. In many states, Medigap is just too expensive for those under 65. But, in some states, Medigap costs about the same for everyone.

Either way, you’ll need to sign up during your Medigap Open Enrollment Period, or during a time when you have guaranteed issue rights, to avoid underwriting eligibility questions.

Can Someone With ESRD Enroll in a Medicare Advantage Plan (Medicare Part C)?

Medicare Advantage ESRD coverage is possible, however, there are stipulations that apply.

Due to recent rule changes, Medicare Part C plans now cover end-stage renal disease patients without restrictions. Further, Part C Special Needs Plans cater to ESRD Medicare patients.

What is the 30-Month Coordination Period for Medicare?

The 30-month coordination period begins on the first date you become entitled to enroll in Medicare due to ESRD. During this time Medicare can be the secondary payer for 30 months.

The coordination period to receive Medicare for ESRD is beneficial for those with employer, COBRA, or retiree coverage. For ESRD patients without other insurance, Medicare is primary at the time of enrollment.

Extension of Immunosuppressive Drug Coverage for ESRD Under Medicare Part B

According to Section 402 of the Consolidated Appropriations Act of 2021 (CAA), immunosuppressive drug coverage under Medicare Part B is now extended for certain people who qualify. Ordinarily, Medicare coverage based on End-Stage Renal Disease (ESRD) would end 36 months following the month of receiving a kidney transplant, should the patient not have other forms of health coverage.

Most people with ESRD can enroll in Medicare even if they are under 65. However, if this is how you qualify, once you receive your kidney transplant, your coverage can be terminated after 36 months if you aren’t eligible through either your age or disability.

Section 402 of Title IV of Division CC of the CAA is extending coverage by providing the opportunity to enjoy a new benefit after a transplant. This includes coverage for immunosuppressive drugs.

The Centers for Medicare & Medicaid Services (CMS) calls this new benefit the immunosuppressive drug benefit or the Part B-ID benefit. Those who qualify can enroll in the new immunosuppressive drug benefit starting in October 2022, with coverage beginning January 1, 2023, at the earliest.

Here are the changes the new rule involving ESRD and Medicare Part B includes:

• Individuals who qualify no longer have specific enrollment periods and can enroll or disenroll, at any time.
• The new benefit will only cover immunosuppressive drugs. Coverage for any other benefit or service related to Medicare Part B doesn’t apply.
• Eligible beneficiaries must prove that they aren’t enrolled in nor expect to enroll in other forms of coverage that include immunosuppressive drugs, such as a group health plan, TRICARE, or Medicaid. Should an enrollee sign up for such coverage, they must notify the Social Security Administration (SSA) within 60 days, ending their enrollment in the Part B-ID benefit).
• Under the new Part B-ID benefit, your monthly premium will be less than the standard Medicare Part B premium, and late enrollment penalties won’t apply. However, there is an annual deductible which, once met, those enrolled will pay 20% of the Medicare-approved amount for immunosuppressive drugs.
• The immunosuppressive drug benefit premium can be covered by states for individuals who qualify for certain Medicare Savings Programs (MSPs). This also applies to Qualified Medicare Beneficiaries (QMBs), co-insurance, deductibles, and cost-sharing.

How to Find a Medicare Plan When You Have End-Stage Renal Disease

Finding an End-Stage Renal Disease Medicare plan when you have a chronic condition can be a challenge. We can help review your plan options and make a recommendation based on your needs.

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