- Medicare covers people of all ages who have ESRD, including children.
- To be eligible, you must be on regular dialysis or have had a kidney transplant.
- Dialysis and kidney transplants are covered under Medicare.
- Even with Medicare, out-of-pocket costs for ESRD treatments and medications may be high, but there are additional coverage options.
End stage renal disease (ESRD) is also known as permanent kidney failure. With this condition, your kidneys can no longer function on their own and you need regular dialysis or a kidney transplant.
Medicare provides medical coverage for eligible people of all ages with ESRD. Even so, you may have various out-of-pocket expenses. These can add up over time, but additional medical coverage is available to help cover these costs.
According to the CDC, treatments for this condition account for around
Many treatments and medications you need to manage ESRD will be covered, in part, by original Medicare (Part A and Part B). Medicare will also cover a portion of the costs for other conditions you may have, as well as preventive care.
Part A covers:
- inpatient dialysis treatments when you’re admitted to the hospital
- kidney registry fee
- full cost of care for a kidney donor
- in-patient hospital care, including medications, therapies, and meals
- surgical procedures, such as arteriovenous fistula creation for dialysis
- limited skilled nursing facility care
- short-term stays in nursing homes
- hospice care
- limited home healthcare
Part B covers:
- outpatient dialysis treatments in a Medicare-approved facility
- at-home dialysis
- home dialysis training, equipment, and supplies
- home support visits by medical professionals and dialysis facility personnel
- doctor’s fees for kidney transplant surgery
- doctor’s fees for your kidney donor while they’re in the hospital
- doctor’s appointments and medically necessary outpatient services
- injectable or oral drugs required for outpatient or at-home dialysis
- emergency room visits
- most screenings and diagnostic tests, including kidney function tests
- most vaccinations, including flu shots
- durable medical equipment
- emergency ambulance services
Medicare Part C
If you have Medicare Advantage (Part C), your plan will cover at least everything that original Medicare does. It may also cover prescription medications that are not covered by Medicare Part B. Part C plans usually require that you use in-network providers and pharmacies.
Medicare Part D
Some medications not covered under original Medicare are covered by Medicare Part D. Part D is an optional prescription drug plan you can purchase from an insurance company.
Not all Part D plans cover the same medications, although every plan is required to provide a standard level of coverage established by Medicare.
The list of drugs a Part D plan will pay for is known as a formulary. Medicare has multiple formulary tiers that set different copay cost levels for different medications. Some tiers just include generic medications, while others include preferred brands, non-preferred brands, or specialty drugs.
Medigap is supplementary insurance that pays for many out-of-pocket costs not covered by original Medicare. You cannot buy Medigap if you’re under 65 or if you have a Part C plan in place of original Medicare.
Medigap supplemental insurance plans may be available for people with ESRD who are 65 or older. These plans cover the gaps that original Medicare doesn’t pay for, such as copays, coinsurance, and deductibles. Medigap does not cover treatments or items that original Medicare doesn’t, such as prescription drugs.
If you have ESRD, you may be eligible for Medicare, no matter your age. To be eligible, you’ll need a written diagnosis of kidney failure from a medical professional. You’ll need to be on regular dialysis or have had a kidney transplant.
Medicare is only available for U.S. citizens or permanent residents who have lived here for at least 5 continuous years.
Your eligibility for Medicare will begin 3 months after the date you start regular dialysis or receive a kidney transplant.
If you’re younger than 65 years old
If you are an adult under 65 years old, you must meet one of the following criteria to be eligible for Medicare:
- you’ve worked the required amount of time (at least 40 quarters or 10 years)
- your already receive Social Security or Railroad Retirement Board benefits
- you have a spouse who meets either of the above criteria
Children with ESRD must have a custodial parent or guardian who has paid Medicare taxes for at least 40 quarters to be eligible for Medicare.
If you only have Medicare because you have ESRD, your coverage will end 12 months after you stop dialysis treatment or 36 months after you have a kidney transplant.
If you’re 65 years or older
If you are applying for Medicare and are turning 65, you or your spouse must have paid Medicare taxes for at least 40 quarters (10 years).
Eligibility for Part C
If you already have ESRD and haven’t had a kidney transplant, you’re currently not eligible for most Medicare Advantage (Part C) plans. You may, however, be eligible for a Special Needs Plan (SNP).
Chronic condition SNPs are designed for people with certain conditions, such as ESRD. The benefits, provider choices, and drug formularies are tailored to meet the needs of people with these complex and ongoing conditions.
Starting in 2021, people with ESRD will be eligible to enroll in a broader range of Medicare Advantage plans. If you wish to change plans, you will be able to do so during the annual open enrollment period, which takes place from October 15 through December 7.
Eligibility for Medigap
If you are under 65 years old, you aren’t eligible for Medigap, even if Medicare is your primary insurance. However, if you’re applying for Medicare because you’re turning 65, you may be able to buy Medigap during your initial 6-month Medigap open enrollment period. During this time, you can purchase any Medigap plan sold in your local area, regardless of any health issues you may have.
If you’re eligible for Medicare due to having ESRD, you can sign up for Medicare Part A and Part B at your local Social Security office or online. If you are a railroad worker, you will need to apply through Social Security.
If you are under 65 years old, your doctor will need to fill out an End Stage Renal Disease Medical Evidence Report, which you will also need to sign.
People with ESRD who have started regular dialysis or who’ve had a kidney transplant can apply for Medicare at any point during the calendar year.
If you are applying for original Medicare or any other parts of Medicare at age 65, there are specific enrollment periods to be aware of.
- Initial enrollment period. This is a 7-month window around your 65th birthday when you can sign up for Medicare. It begins 3 months before your birthday, includes the month of your birthday, and extends 3 months after your birthday. During this time, you can enroll for all parts of Medicare without a penalty.
- Open enrollment period. Medicare’s open enrollment runs from October 15 to December 7. During this time, you can switch from original Medicare to Part C, or from Part C back to original Medicare. You can also switch Part C plans or add, remove, or change a Part D plan.
- General enrollment period. This enrollment period runs each year from January 1 through March 31. You can enroll in Medicare during this time if you did not enroll during your initial enrollment period.
- Special enrollment period. If you delayed Medicare enrollment for an approved reason, you can later enroll in Medicare during a special enrollment period. You have 8 months from the end of your coverage or the end of your employment during which to sign up without penalty.
- Medigap enrollment. This 6-month period starts after the first day of the month that you apply for original Medicare, or from your 65th birthday. If you miss this enrollment period, you may not be able to get a Medigap plan. If you do get one, you may pay higher premiums for it.
If you are currently comparing Medigap, Part D, or Part C plans, you can use Medicare’s plan comparison tool to see what plans are available where you live, as well as their costs and coverage options.
If your kidneys become damaged and are unable to do their job, kidney failure may eventually occur. Approximately 750,000 people in the United States have ESRD. People with ESRD account for 1 percent of the U.S. Medicare population, but 7 percent of its annual budget.
The most common cause of kidney damage is diabetes, followed by high blood pressure. Urinary tract problems, autoimmune diseases such as lupus, and genetic conditions such as polycystic kidney disease or Alport syndrome can also be the cause.
Even if you have one or more of these conditions, there are ways to prevent kidney failure. Strategies include eating a heart-healthy diet, staying well hydrated, and limiting your salt intake.
Kidney failure (ESRD) is the final stage of kidney disease. At this point, you will need dialysis or a kidney transplant.
Kidney failure cannot be cured once it occurs. However, dialysis and kidney transplants allow people to live long, happy, and productive lives, even with this condition.
People with ESRD may enroll in Medicare at any age. To be eligible for Medicare, you will need to be on regular dialysis or have had a kidney transplant.
Different parts of Medicare cover different treatments. For example, in-patient dialysis is covered by Medicare Part A, whereas outpatient or at-home dialysis is covered by Medicare Part B.
If you are younger than 65 and are receiving Medicare for ESRD, your coverage will end 36 months after you have a kidney transplant or 1 year after you no longer need dialysis.
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