Does Medicare cover End-Stage Renal Disease?

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People with End-Stage Renal Disease (ESRD) or kidney failure can begin receiving Medicare benefits during their fourth month of dialysis treatment or when hospitalized for a kidney transplant. This is defined as three months after beginning a course of dialysis treatment. If you opt for at-home dialysis (known as a self-dialysis training program), you can begin coverage as early as the first month of dialysis. If you stop this at-home regimen and go to an outpatient dialysis treatment center, your three-month waiting period will start over and you will receive benefits on the first day of the fourth month of treatment.

Qualify for Medicare

End-Stage Renal Disease does not automatically qualify you for premium-free Part A. You will pay premiums for Part A and Part B unless you otherwise qualify to receive Part A without paying a premium. The Part B premium in 2021 is $148.50. It is important for ESRD patients to enroll in Part B because Part B will cover your outpatient dialysis treatments.

In 1972, legislation made it possible for patients with stage five chronic kidney disease (CKD) to receive Medicare benefits, regardless of age. ESRD patients first received Medicare benefits in July of 1973. In 2021, people with End-Stage Renal Disease will finally be eligible to join a Medicare Advantage plan, thanks to the 21st Century Cures Act. Medicare Advantage plans will be guaranteed an issue for all Medicare beneficiaries, including patients with ESRD.

If ESRD is the only reason you qualify for Medicare (you are under 65 and do not qualify thanks to another disability), you have a limited period of time in which you are covered for treatment. You qualify to receive Medicare benefits for 12 months following your last month of kidney dialysis. If you have a kidney transplant, you are eligible for Medicare for 36 months following the kidney transplant. The legislation was introduced in 2019 to extend the length of coverage for transplant patients reliant on immunosuppressants, but it has not yet been enacted.

If you have private health insurance in addition to Medicare benefits related to ESRD, your private insurance will be the primary payer for medical treatment for the first 30 months of receiving Medicare benefits. After this time has passed, Medicare will become the primary insurer.

Medicare Supplements

More than half of this country’s states have guaranteed-issue rights allowing people with ESRD to enroll in Medigap (Medicare Supplement) plans. In the remaining states, you can be turned down if you are under age 65 and only qualify for Medicare because of ESRD. Original Medicare does not have an out-of-pocket limit on costs, so the 20 percent in cost-sharing adds up with each treatment. Having a Medicare Supplement plan can help reduce these expenses. All of the available plans cover Part B copays and coinsurance in full once you meet the deductible, with Plan K covering it at 50 percent and Plan L covering it at 75 percent. If you sign up for a Medigap plan, you cannot enroll in a Medicare Advantage plan, and vice versa: there may only be one.

For more information about how Medicare covers those with ESRD, reach out to Bobby Brock Insurance today.

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Justin Brock

President & CEO of Bobby Brock Insurance