End-Stage Renal Disease and Medicare: What You Need to Know

Medicare coverage isn’t just for those age 65 and over. Some medical conditions can qualify you for Medicare, regardless your age. Similar to some benefits of Social Security, Medicare is available for people under 65 who have special life or health situations and who meet certain criteria.

End-Stage Renal Disease (ESRD) is a medical diagnosis that makes Medicare coverage an option at any age, once certain criteria are met. Let’s get to know the basics of this health condition and what is important to know about receiving care and treatment using Medicare coverage.

What is End-Stage Renal Disease?

Affecting nearly 786,000 Americans (1 in 500), End-Stage Renal Disease (sometimes referred to as End-Stage Kidney Disease) is when you have been diagnosed with permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

The statistics on ESRD are sobering. Approximately 70% are on dialysis, either at home or at a medical facility, while 30% have been able to receive a kidney transplant. Quality of life and lifespan are increased with a kidney transplant, but the waiting lists are long. Most ESRD patients wait 3 - 4 years for a transplant while they are receiving dialysis.

Most ESRD patients had been living with Chronic Kidney Disease (CKD) for years, even if they did not know it. Affecting 1 in 7 adults, CKD has few obvious symptoms and is easy to miss until the disease progresses further. However, other health conditions put you at higher risk of CKD — 1 in 3 people with diabetes and 1 in 5 people with high blood pressure have CKD. Simply knowing this can help you better monitor your health if you have diabetes or high blood pressure. Asking for basic kidney function blood tests during your annual checkup is another way you can monitor for CKD.

Even if CKD progresses into ESRD, people are able to live full lives and can enjoy their families and hobbies, with attention to their health and monitoring and managing symptoms. That’s why it is important to make sure that health coverage is in place when living with ESRD — this is where Medicare has stepped in to help.

All About Medicare with ESRD

Medicare covers patients with ESRD, even if they are younger than 65. This helps to keep overall quality of life higher for patients and costs lower for everyone. Did you know that Medicare spends approximately $49 billion annually (as of 2018) on Medicare services for patients with ESRD?

Qualifying for Medicare with ESRD

A few conditions must be met for a patient with kidney disease to obtain Medicare coverage.

First, you must be diagnosed with ESRD by a doctor, who determines that:

• Your kidneys no longer work
• You need regular dialysis or have had a kidney transplant

Then, a patient must meet one of these criteria:

• Worked the required amount of time under Social Security, the Railroad Retirement Board (RRB) or as a government employee
• Already getting or are eligible for Social Security or Railroad Retirement benefits
• Are the spouse or dependent child of a person who meets either of the requirements listed above

Benefits under Medicare with ESRD

Once Medicare coverage is obtained, the patient will be assigned to a care team who can help manage and monitor health and treatment plans.

The effective date of ESRD Medicare is dependent on the type of treatment you are receiving.

Hemodialysis – Medicare is effective in the fourth month of treatment. For example, if hemodialysis is started in May, Medicare becomes effective on August 1.

Home or Self-Dialysis – Medicare is effective the first month of treatment if all three of these criteria are met:

1. You take part in a Medicare-certified training program
2. The training begins within the first three months of treatment
3. You are expected to finish home training and self-dialyze at home

Transplant – Medicare is effective:

1. The month you are admitted to a Medicare-certified hospital for a kidney transplant or for health care needed prior to transplant. The transplant must then take place within two months.
2. Two months prior to your transplant if the transplant is delayed more than two months after you are admitted to the hospital in anticipation of transplant or related health services.

You may also obtain coverage after a lapse if you stopped ESRD treatment for a period of time and then restarted treatment.

In some cases, initial Medicare coverage with ESRD can be retroactive. For more details, please refer to the official Medicare website on ESRD.

Signing up for Medicare with ESRD

If you’re eligible for Medicare because of ESRD and you qualify for Part A, you can also get Part B. Don’t forget that you’ll need both Part A and Part B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services.

Note: If you waited too long to apply for Medicare Part B and would be subject to a late enrollment penalty, this penalty will be waived if you are approved for Medicare because of ESRD.

When you sign up for Medicare with ESRD, you have the same plan choices as someone without ESRD. You may sign up for original Medicare only, add a Part D prescription drug plan, add supplemental coverage or sign up for Medicare Advantage which may offer additional benefits.

Conclusion

If you are living with ESRD, Medicare gives you coverage that can help you stay healthier while enjoying the things you love. Because this can be a complicated topic, check the official Medicare page about ESRD for more details, or talk to a trusted advisor. We hope we’ve given you an overview of what End-Stage Renal Disease is and how it affects you and your healthcare coverage.

And if you have any questions about Medicare or Medicare coverage with ESRD, please feel free to give us a call. One of our PlanEnroll agents will be happy to help you.

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