ESRD and Medicare Coverage

Because End-Stage Renal Disease (ESRD) is a serious medical condition that affects many people, understanding ESRD and Medicare coverage is very important for agents and beneficiaries. For individuals who suffer from ESRD, it is essential to access needed healthcare coverage to manage this condition. Luckily, Medicare provides coverage designed to meet the needs of ESRD patients. In this post, we discuss ESRD it’s affects and the ways Medicare covers the treatments.

What is ESRD

End-Stage Renal Disease (ESRD) is also know as end-stage kidney disease or kidney failure. ESRD occurs when an individual suffers a gradual loss of kidney function until the final stage where waste builds up in the body to a dangerous level. Once an individual reaches the final stage or ESRD, kidneys no longer function requiring medical treatment. Treatments include dialysis or a kidney transplant to keep individuals alive.

There are several symptoms of ESRD that may include the following:

1. Nausea/vomiting
2. Loss of appetite
3. Changes in urination
4. Fatigue and weakness
5. Headache
6. Fluid retention and swelling (edema) in feet and or ankles
7. High blood pressure (hypertension)
8. Chest pain if fluid builds up around the heart
9. Shortness of breath
10. Muscle cramps or twitching
11. Anemia
12. Bone disease
13. Cardiovascular problems
14. Complications related to dialysis or transplantation

The management of ESRD requires a multidisciplinary approach. Individuals must adhere to a strict schedule of medical appointments and treatment regimens. This may involve dietary restrictions, and changes to lifestyle.

Enrolling in Medicare for ESRD

Individuals who need to enroll in ESRD Medicare should go to their local Social Security office. Social Security handles ESRD Medicare enrollments. Providers and/or dialysis centers must send documentation to the Social Security office to verify ESRD and explain each individual’s course of treatment. For those too ill to enroll themself, a family member or designated person can enroll you.

ESRD and Medicare Coverage

Medicare provides tailored coverage options for individuals with ESRD. In general, Medicare eligibility for individuals who suffer from ESRD begins either immediately if they are recieving dialysis or after a kidney transplant.

When does ESRD Medicare coverage start

The start of Medicare coverage of ESRD depends on the treatment plan.

1. Those who start a home dialysis training program (self-dialysis), will be Medicare eligible the first day of the first month the home dialysis program starts. Patients must start the program before the third month of dialysis. In addition, the doctor must verify they expect the patient to complete the program and continue home dialysis once the program ends.
2. Anyone who receives dialysis either at an in-patient or out-patient facilty is eligible for Medicare the first day of the 4th month they receive dialysis. In other words, if an individual recieves dialysis on Feb 20, they are eligible for ESRD Medicare on May 1st.
3. For those who receive a kidney transplant, Medicare coverage begins the month they are admitted to a Medicare approved hospital for the transplant or when they recieve needed health services before the transplant.
4. Individuals must receive the transplant within 2 months after the Medicare coverage starts.

Medicare’s coverage of ESRD

Medicare Part A

Medicare Part A (hospital Insurance) covers inpatient kidney transplants or dialysis at a Medicare-approved facility. Please note; individuals must meet the hospital deductible before Medicre pays. In 2024, the deductible is $1,632. Additionally, If the beneficiary is in the hospital in excess of their benefit period, they pay daily co-insurance.

Medicare agents looking for free training videos; click here visit out YouTube channel

Medicare Part B

Medicare Part B (Medical Insurance) provides coverage for doctors’ visits, outpatient care, medical supplies as well as a portion of dialysis treatments. This includes dialysis equipment and supply costs and fees for transplant surgeons. Generally, patients pay a 20% coinsurance if they choose a provider that accepts Medicare assignment.

Important; Medicare pays for the kidney donor’s hospital stay and follow-up care. There is no cost sharing for the donor’s care. The recipient of the kidney should not recieve a bill for the donor’s care.

Outpatient dialysis

As long as the patient receives outpatient dialysis in a Medicare approved facility, Part B covers the cost. In most cases the patient pays 20% coinsurance for each session. This includes most dialysis medications, equipment, supplies and lab tests.

Home dialysis

Medicare Part B provides coverage of certified home dialysis. They pay a set fee that includes the training cost to learn to administer home dialysis. Supplies, lab tests, most dialysis medications, and home dialysis equipment are included in the fee Medicare pays. Again, most patients pay 20% coinsurnace toward treatment cost.

Please note: ESRD Medicare does not cover surgery or cost for services needed to prepare the patient for dialysis before they are Medicare eligibile. In other words, Medicare does not pay the cost of surgery to create the access point for a dialysis machine. Patients who have coverage prior to Medicare, will use that coverage to pay the costs for services.

Immunosuppressants

Medicare Part B will covers immunosuppressants for patients who:

1. Are only eligible for ESRD Medicare. Medicare coverage ends 36 months after a successful transplant.
2. Were enrolled in Medicare Part A when they received the transplant.
3. Are enrolled in Medicare Part B when they fill their immunosupressant prescrptions.

Once a patient receives a transplant, they must take immunosuppressant drugs for life to prevent rejection of the new kidney.

If the patient was not enrolled in Medicare Part A when they got transplant surgery, Part B will not pay for immunosuppressants. This is true even for those whpo had other insurance coverage that paid for the transplant surgery. Patients not enrolled in Part A when they received their transplant may need Medicare Part D to cover the costs of immunosuppressants.

Immunosuppressive drug benefit

Patients who’s ESRD Medicare benefits reach their end, 36 months after a transplant, may be eligible for the Medicare immunosuppressive drug benefit (Part B-ID benefit). This benefit covers only immunosuppressant drugs. It does not cover any other Part B benefit or services. If the patient has other insurance options, Part B-ID may not be a great choice.

How to qualify for Part B-ID

1. The patient must not be on Medicaid or other health insurance plan that covers immunosuppressants.
2. Patients must qualify for Part B immunosuppressants before the loss of Medicare ESRD coverage.

The cost for Part B-ID coverage is a set percentage of the standard Part B premium. To enroll in the plan, contact Social Security 877-465-0355.

Medicare Part C

Medicare Part C (Medicare Advantage) plans provide the same benefits as Original Medicare (Parts A and B) but may have seperate cost restrictions. Medicare Advantae plans cannot set higher cost sharing for either outpatient dialysis or immunosuppressant drugs then Original Medicare. In many cases, Part C (Medicare Advantage) plans include addtional benefits like dental, vision, OTC and prescription drug coverage. There are some Medicare Advantage plans that offer specific coverage for individuals with ESRD.

Medicare Part D

Medicare Part D (Prescription Drug Coverage), provides coverage for prescription medications. This includes those required for ESRD treatment.

Other insurance coverage

Those enrolled in private or employment based insurance when they become eligible for ESRD Medicare will have their private or employer based coverage as primary for 30 months. The 30 months begin as sson as the patient is eleigible for ESRD Medicare even if they did not sign up for it.

The 30 months are referred to as the coordination period. It begins the month they are eligible for ESRD Medicare coverage. During this time, patients do not have to sign up for ESRD Medicare immediately as long as their private or employment based insurance is in effect. The existing insurance pays first and ESRD pays second for health costs. In the event the patient does not have othe rcoverge, ESRD Medicare pays as soon as it goes into effect.

It is a good idea to enroll in ESRD even if your current coverage pays as primary during the 30 month period. Medicare ESRD may help cover deductibles, copays as well as coinsurance. Enrolling in ESRD Medicare when the 30-month coordination period begins will automatically make Medicare ESRD the primary payer at the end of the coordination period.

ESRD coverage end

Those enrolled in Medicare soley due to ESRD will lose coverage due to the following:

1. If the patient no longer requires dialysis, coverage ends 12 months after the last treatment date.
2. When the patient has a successful transplant; meaning the new kidney is not rejected after 36 months. At that time, Medicare ESRD coverage ends.

Medicare provides comprehensive coverage for those who are living with ESRD. Understanding the ESRD coverage provided by Medicare helps individuals effectively manage this condition.