Medicare Basics: End Stage Renal Disease (ESRD)

Medicare is often thought of as national health care coverage for those aged 65 and older, but that’s not always the case. Younger people who have kidney problems leading to end-stage renal disease (ESRD) can also qualify for Medicare, regardless of age. ESRD occurs when kidneys stop functioning (permanent kidney failure) and require regular, long-term dialysis treatments or for those receiving kidney transplants.

You must meet certain requirements to qualify for Medicare based on ESRD, and coverage doesn’t begin right away. But you don’t have to be on Social Security Disability Insurance (SSDI) to qualify.

You may want additional coverage to help pay for services ESRD Medicare doesn’t cover. If you’re still insured by an employer or union group health plan, you should also understand how Medicare works with your group health coverage. Here’s what you should know about ESRD Medicare before you enroll.

If you’re a kidney disease patient who has ESRD, you may be eligible for Medicare regardless of your age, or if you’re on Social Security Disability Insurance (SSDI). You can get Medicare if:

• Your kidneys no longer work
• You have had a kidney transplant or need regular dialysis
• You, your spouse or dependent child has worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee, OR you are already eligible for or getting Social Security or RRB benefits.

Contact Social Security or the RRB about the amount of time required to be eligible for Medicare.

End Stage Renal Disease (ESRD) Medicare coverage gives you access to:

• Medicare Part A, which covers inpatient hospital stays or temporary time at a skilled nursing facility and some home health care services and hospice care, and
• Medicare Part B, which helps pay for doctors’ services, outpatient care, medical supplies, and preventive services.
• Kidney transplants
• Hospital inpatient dialysis
• Outpatient dialysis from Medicare-certified facilities
• Home dialysis training, equipment and supplies for you or your caregiver
• Medications related to treatment

Medicare usually doesn’t pay for:

• Transportation to a dialysis facility
• Paid dialysis aides to help with home dialysis training
• Income lost due to home dialysis training
• A place to stay during treatment
• Blood or red blood cells for home dialysis treatment unless these are included in a doctors’ services.
• Services outside of the U.S. Exceptions to this are:

• • if you’re in the U.S. when the medical emergency occurs and a foreign hospital is the nearest hospital that can treat you;
  • if you’re traveling through Canada to a U.S. state by the most direct path and the Canadian hospital is closer than a U.S. hospital; or
  • if a foreign hospital is closer to where you live than the nearest U.S. hospital that can treat your condition.

If you have Original Medicare, you can purchase a Medigap policy to supplement your coverage. Medigap may help pay for services received outside the U.S., including dialysis, if your care begins during the first 60 days of your trip and isn’t covered.

If you get your benefits through a Medicare Advantage Plan instead of Original Medicare, you cannot purchase a Medigap policy. MAPs do not typically provide services outside of the U.S., but your plan may allow you to receive services outside of your network in case of an emergency.

Medicare Part B, which you can receive based on ESRD, provides coverage for transplant drugs after you receive a covered kidney transplant as well as many dialysis drugs, but it doesn’t cover prescription medications for other health conditions. To receive help paying for prescriptions unrelated to ESRD, you’ll need Medicare Part D.

If you qualify for End Stage Renal Disease (ESRD) Medicare coverage, you can join a Medicare drug plan during your seven-month enrollment period. This period starts three months before the month you become eligible for Medicare and ends three months after that month. Alternatively, if you qualify for ESRD Medicare, you can choose a MAP with drug coverage.

If you are eligible for Medicare due to End Stage Renal Disease, you can get a Medicare Advantage Plan. You must be enrolled in Medicare Parts A and B and can choose from available plans in your area. You will likely have access to an HMO or PPO plan with drug coverage. ESRD qualifies you for a unique Medicare Advantage Plan called Chronic Condition Special Needs Plans (C-SNPs), but they are not as widely available. Search for plans in your area on the Medicare website.

Most MAPs offer extra benefits that are not included with Medicare, such as drug coverage, hearing, vision, and dental. Most HMOs and C-SNPs require you to use network providers, so make sure your preferred providers and facilities are in network for the plan you choose. PPOs allow you to see out of network providers, but you pay more out-of-pocket costs.

Medicare Advantage Plans are the alternative to regular Medicare. If you choose a MAP, you cannot purchase a Medigap plan.

The coverage start date depends on your condition and treatment.

If you’re on dialysis:

• There is a four-month waiting period. Coverage usually begins the first day of the fourth month of your dialysis treatments, regardless of when you sign up or if you’re still covered by an employer health plan.
• You can avoid waiting four months and have your ESRD Medicare coverage start the first month of your dialysis treatments if:
• if you participate in a home dialysis training program through a Medicare-certified training facility during the first three months of your dialysis treatments, or
• your doctor says you’ll finish training and be able to perform your own dialysis treatments.
• ESRD Medicare can be applied retroactively up to 12 months before the month you apply. If you are already receiving Medicare, or if you have completed your home dialysis training program, your coverage should include preparatory surgery and services for dialysis.

If you’re getting a kidney transplant:

• Your coverage for ESRD Medicare could begin the month you’re admitted to a Medicare-certified hospital for your kidney transplant, provided the transplant occurs within two months.
• For transplants that are delayed by more than two months after you’re admitted to the hospital, Medicare coverage begins two months before your kidney transplant occurs.

Your ESRD Medicare coverage end date is 12 months after the month you stop dialysis or 36 months after your kidney transplant. Coverage can resume if you start dialysis again, get a kidney transplant within 12 months of when you stopped dialysis or get another kidney transplant within 36 months of your previous kidney transplant.

Monthly premiums:

You’ll receive premium-free Medicare Part A if you qualify for Medicare coverage based on End Stage Renal Disease. Medicare Part B has a premium, which is either deducted from your Social Security or RRB benefits or billed to you. In 2022, the standard Part B premium, which most people pay, is $170.10 per month. If your annual income is above $91,000 (individual) or $182,000 (joint) you will pay more.

Deductibles, copays, and coinsurance:

The Part B deductible in 2022 is $233. After you reach this amount in payments, you’ll generally only pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy, and durable medical equipment (DME). If you have Parts A and B with a Medigap plan, the 20% coinsurance is covered. If you have a MAP, you may be responsible for copays or coinsurance, depending on your plan’s network.

Late enrollment penalty:

ESRD can absolve you of the late enrollment penalty levied on those who don’t sign up for Medicare Part B on time. If you’re already enrolled in Medicare when you become ESRD eligible and have been paying a Part B late enrollment penalty, the penalty will stop when you become ESRD Medicare eligible. You’ll need to contact your local Social Security office to re-enroll in Medicare based on ESRD.

If you’re eligible for Medicare due to ESRD, you can enroll in Medicare Part A and Part B online through Social Security. You may be able to make an in-person appointment if your case cannot be handled easily on the phone. The Medicare hotline is still available to answer questions at (800) 633-4227.

The online application process usually doesn’t require any documentation or signatures and takes only 10 minutes. Be prepared to provide:

• Your date and place of birth;
• Medicaid number and start and end dates, if applicable;
• Permanent Residence Card number if you aren’t a U.S. citizen, and
• The start and end dates for your current health coverage through your or your spouse’s employer.

You can enroll in Medicare because of ESRD even if you have employer or union group health plan coverage. More details on how ESRD Medicare works with other coverage are provided below.

When you enroll, you’ll also have the option of choosing a Medicare Advantage Plan with drug coverage, or a stand-alone Part D prescription drug plan if you keep traditional Medicare. You’ll have the option to change your plan elections each year.

Since ESRD Medicare doesn’t start right away, you may want to keep your employer or union plan, which can help pay for treatments during the three-month waiting period before coverage begins.

ESRD Medicare is unique because of the three-month waiting period before coverage begins and a “30-month coordination period,” which is explained below. Medicare.gov provides a helpful resource about ESRD Medicare on a national level, and you can contact your State Health Insurance Assistance Program (SHIP) to discuss your options.

30-month coordination period:

Once you become eligible for ESRD Medicare, which usually occurs in your fourth month of dialysis, there will be a 30-month “coordination period” when your employer or union group health plan continues to pay your medical bills. This coordination period begins the first month you become eligible for ESRD Medicare, even if you haven’t signed up for Medicare yet.

During the coordination period, your group health plan pays first and Medicare pays second. This means that if your group plan doesn’t pay all of your health care bills during this time, Medicare may cover some of the remaining costs. This may include help paying your deductible, copayment, or coinsurance.

At the end of the coordination period, Medicare will pay first for all services covered by your plan and your group health plan may help pay remaining costs.

There will be a new 30-month coordination period each time you enroll in Medicare due to ESRD even if you don’t have the three-month waiting period for Medicare to begin. For example, if you have a kidney transplant that works for 36 months, and you don’t turn 65 during that time period, your Medicare coverage will end. If you then start dialysis again later and re-enroll, your coverage will begin immediately. However, there will still be a new 30-month coordination period if you’re still on a group health plan.

When to enroll in Medicare if you have a group health plan:

If your health plan covers most or all of your services, you may want to delay enrolling in Medicare until the 30-month coordination period is over. This way, you won’t have to pay the Part B premium that you don’t need. You won’t incur a penalty premium for delaying Part B coverage in such a situation. If your group health plans stop or are decreased, you should enroll in Medicare as soon as possible.

If you haven’t enrolled in Medicare yet, you could also get a Health Insurance Marketplace plan instead, which may provide tax credits or reduced cost-sharing options. Many states have agencies and kidney programs to help with the health care costs Medicare doesn’t cover. Contact your SHIP to learn more about your state’s coverage options.

Tell your health care services provider if you have employer or union coverage to ensure the services are billed correctly.

• CMS: End-Stage Renal Disease (ESRD) | Last accessed October 2022
• HHS: U.S. Department of Health & Human Services: Who is Eligible for Medicare? | Last accessed October 2022
• Medicare: I Have End-Stage Renal Disease (ESRD) | Last accessed October 2022
• Medicare: Dialysis Services & Supplies | Last accessed October 2022
• Medicare: Travel Medical Coverage | Last accessed October 2022
• Medicare: Medigap and Travel | Last accessed October 2022
• Medicare: Drug Coverage (Part D) | Last accessed October 2022
• Medicare: How do Medicare Advantage Plans Work? | Last accessed October 2022
• Medicare: Part A Costs | Last accessed October 2022
• Medicare: Part B Costs | Last accessed October 2022
• State Health Insurance Assistance Programs | Last accessed October 2022
• SSA: Medicare Benefits | Last accessed October 2022