End-Stage Renal Disease (ESRD) Medicare Coverage
End-stage renal disease, often abbreviated at ESRD, is a form of kidney failure that is treated differently by Medicare for coverage purposes. To be covered by Medicare you must have permanent kidney failure that requires dialysis or a kidney transplant.
What is End-Stage Renal Disease?
ESRD is the last stage of chronic kidney disease. The kidneys are organs that extract waste from the blood, form urine, and balance your fluids. The human body cannot survive without at least one properly functioning kidney.
Kidney dysfunction is most commonly the result of diabetes or high blood pressure. Autoimmune diseases, some genetic diseases, nephrotic syndrome, and urinary tract problems can also lead to kidney failure.
Why does Medicare cover ESRD?
In 1972, Medicare benefits were extended to cover the high costs of providing care to people with permanent kidney failure. To this day, ESRD is only one of two medical conditions that give Medicare beneficiaries the option of enrolling in Medicare without a two-year waiting period.
Since that time, some additional and specific rules have been added to further clarify coverage for this deadly condition.
Chronic Kidney Disease Stages
The National Kidney Foundation has established six stages of chronic kidney disease to help doctors understand where their patients are in the disease’s development.
The stages are measured mainly according to your GFR, or glomerular filtration rate, which is calculated according to age, race, gender, and serum creatinine. Creatinine is body waste that comes from muscle activity and reflects kidney function.
Stage One: GFR equal to or greater than 90 mL/min
Stage Two: GFR between 60 and 89 mL/min
Stage Three A: GFR between 45 and 59 mL/min
Stage Three B: GFR between 30 and 44 mL/min
Stage Four: GFR between 15 and 29 mL/min
End-Stage Renal Disease: GFR less than 15 mL/min
Chronic Kidney Disease Symptoms
When your kidneys start failing, you may notice the following symptoms:
- muscle cramps
- loss of appetite
- changes in your urine cycle
- swollen feet and ankles
- trouble sleeping and
- trouble catching your breath
Some people may also experience stomach and back pain, diarrhea, fevers, nosebleeds, and even rashes.
ESRD Medicare Eligibility and Enrollment
According to the Centers for Medicare and Medicaid Services (CMS), to qualify for ESRD Medicare, you must be under 65 years old and be diagnosed with ESRD by a doctor.
You must also have a sufficient work history to qualify for Social Security Disability Insurance (SSDI) or Social Security benefits. You can also qualify if you have enough railroad work history to qualify for Railroad Retirement benefits or you are eligible to receive a railroad disability annuity.
You can use the work history of your spouse or a parent to qualify as well.
To verify your eligibility for ESRD Medicare, contact Social Security at 800-772-1213
Your ESRD Medicare coverage start date will be as follows:
- If you have home dialysis, it will begin on the first day of the first month of home dialysis
- Those receiving dialysis through a facility will start coverage on the first day of the fourth month of dialysis
- If you receive a kidney transplant, coverage will begin in the month you are admitted to the hospital/begin transplant preparation services or two months before your transplant
In most cases, you can’t enroll in a Medicare Advantage Part C plan if you are eligible for ESRD Medicare. But there are a few exceptions:
- You can enroll in a Medicare Advantage Special Needs Plan (SNP) if it specifically covers people with ESRD. SNPs are set up to meet specific conditions and you can only join an SNP if you fit the condition that the plan serves. SNPs may have limited geographic coverages. Call 1-800-MEDICARE to see if there is an SNP that provides ESRD coverage in your area.
- If you have job-based insurance, and that same company offers a Medicare Advantage Plan, you can sign up in that company’s Medicare Advantage Plan.
Also, if you signed up for a Medicare Advantage Plan before you were diagnosed with ESRD, your provider can’t drop you from coverage.
If your provider leaves Medicare or moves out of your service area, you can enroll in another SNP during a Special Enrollment Period.
What is the 30-Month Coordination Period?
If you have other types of health coverage, such as job-based insurance, COBRA or retired medical, you do not need to enroll in Medicare immediately when you become eligible due to ESRD.
Your other insurance will remain your primary insurance for 30 months, beginning the first month you become eligible for ESRD Medicare. This is called the 30-Month Coordination Period.
During this 30-Month Coordination period:
- Your group health plan must pay first (primary payer) and ESRD Medicare may pay second for your health care costs (secondary payer). If you don’t have other health insurance, ESRD Medicare will become the primary payer as soon as you sign up.
- Even if you have group health insurance, you should sign up for ESRD Medicare to assist you with expensive cost-sharing related to deductibles, copayments, and coinsurances.
- You can enroll in Medicare Part A and Part B at any time during your 30-month coordination period. You must sign up for both at the same time. If you delay ESRD Medicare, you should turn down Part A and Part B. This is because if you enroll in Part A and delay Part B, you lose your right to enroll at any time during the 30-month coordination period. You will have to wait for the General Enrollment Period and could face enrollment gaps and penalties.
When the 30-month coordination period is over, Medicare automatically becomes primary and your group health plan coverage becomes secondary.
This 30-month coordination period is for people with ESRD Medicare only. If you have Medicare due to age or disability before being diagnosed with ESRD, normal rules about coordinating with other insurance providers will apply.
If your ESRD Medicare coverage ends, and later there is the need to resume coverage, you will start a new 30-month period.
If you have COBRA when you enroll in ESRD Medicare, your employer has the option to end your COBRA coverage. Whether they do or not varies by employer. However, if you have ESRD Medicare coverage first and then qualify for COBRA, your employer must offer you coverage, and it will become the primary payer during the 30-month coordination period.
What Does ESRD Medicare Cover?
Medicare covers the following care related services for ESRD:
- Kidney transplants
- Hospital inpatient dialysis
- Outpatient dialysis from a Medicare-certified hospital or free-standing dialysis facility
- Self-dialysis (home dialysis) training from a dialysis facility, including patients and caregivers who will provide home dialysis
- Home dialysis equipment and supplies
- If you need dialysis when you travel. There are about 6,000 dialysis facilities around the country and your social worker can assist you in setting up treatment on your route before you travel.
- Medications related to treatment (must be overseen by a doctor)
- Immunosuppressant drugs after a kidney transplant (you must have Part A coverage at the time of the transplant)
- Immunosuppressant drugs after a kidney transplant, as long as you had Medicare Part A at the time of the transplant
- Medicare covers most ESRD treatment related services, with standard Original Medicare cost-sharing. That means Original Medicare pays some of the costs of your treatment and you cover the rest. Your costs for ESRD care also depend on your treatment plan.
- Ambulance services to and from your home to the nearest dialysis facility for ESRD treatment only if other forms of transportation endanger your health. For non-emergency, scheduled, repetitive ambulance services, the ambulance supplier must get a written order from your doctor before you get the ambulance service. The doctor’s order must certify ambulance transportation is medically necessary.
Medicare does NOT cover surgeries and services involved in the dialysis preparation process, such as the surgery that creates an access point for your dialysis machine. To get more coverage for hospital services, you may need to enroll in an SNP.
ESRD Coverage for Children
Medicare provides coverage for people of all ages who have ESRD. Your child is covered if you or your spouse meet work requirements under Social Security, the Railroad Retirement Board, or as a government employee.
Your child is also covered if you, your spouse, or your child get Social Security or RRB benefits, or are eligible to get those benefits.
Immunosuppressant Drug Coverage
After you get a kidney transplant, you must take immunosuppressant drugs to prevent your body from rejecting your new donor kidney. You will need to take these drugs for the rest of your life.
Medicare covers these drugs differently depending on your particular circumstances.
Limited Part B Coverage
If you get a kidney transplant in a Medicare-approved facility, Part B will cover your immunosuppressant drugs for 36 months after discharge if you meet the following criteria:
- You had Part A when you had your transplant
- You have Medicare Part B when filling your prescriptions
- You are only eligible for ESRD Medicare
Medicare coverage will end 36 months after the month of a successful transplant
Also, if you didn’t have Medicare when you had a transplant, you can retroactively enroll in Part A within a year of your transplant.
Lifelong Part B Coverage
When you receive a kidney transplant in a Medicare-approved facility, Part B will cover your immunosuppressants for the rest of your life if you meet the following criteria:
- You had Part A when you had your transplant
- You have Medicare Part B when filling your prescriptions
- You qualify for Medicare based on age or disability
Part D Coverage
If you don’t have Part A when you get a transplant, your immunosuppressants will be covered by Part D afterward.
The drawback is that Part D coverage for immunosuppressants means higher costs and more restrictions, such as limited and specific in-network pharmacy choices.
All Part D formularies must include immunosuppressant drugs. You may need to seek prior authorization for Part D coverage, meaning that your plan will need to verify that Part B does not cover your required drugs before providing you with coverage.
Also, after dialysis, you need to take vitamins to replenish vitamins in your blood. Medicare usually does not cover these vitamins, but some Part D plans may offer coverage that does. Check a plan’s formulary to see if they are covered prior to joining if this is an issue for you.
Costs of ESRD Medicare
Despite ESRD Medicare coverage, you will still have costs associated with your treatment and services.
You will have to meet your deductible before Medicare Part A and Part B cover your dialysis treatments. You must also pay your monthly premium for Part B which is $144.60 per month in 2020.
In 2020, the standard Part A (hospital treatments and services) deductible is $1,408. The standard 2019 Part B (doctor visits and home health) deductible is $198.
Therefore, before your Medicare coverage kicks in, you’ll have to spend $1,408 on hospital services and $198 on doctor and home health services.
In addition to deductibles, for hospital services, if you have Original Medicare, you’ll pay:
- Days 1–60: $0 coinsurance for each benefit period
- Days 61–90: $352 coinsurance per day of each benefit period
- Days 91 and beyond: $704 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)
- Beyond lifetime reserve days: all costs
For most Part B services, you will have to pay 20% coinsurance, but Medicare Part B will cover the other 80%.
Unless you qualify for Medicare for another reason, your coverage will end 12 months after you stop your dialysis treatments.
End-Stage Renal Disease Life Expectancy
Life expectancy after your diagnosis depends on age and sex. Women typically have a higher life expectancy in general. A 70-year old man in stage one will live on average nine years post-diagnosis, while a woman in the same stage will more likely live 11 years post-diagnosis.
Most people in stage four or five of chronic kidney disease will typically live for about four years post-diagnosis. Those who receive a kidney transplant are more likely to live 15 years post-diagnosis.
ESRD Treatment Options
People with end-stage renal disease will require dialysis or a kidney transplant. There is no cure, but dialysis and transplants can diminish symptoms, improve quality of life, and extend life expectancy.
Dialysis is defined as machine-assisted kidney function. You are connected to a machine that performs functions such as separating your fluids, removing wastes, and purifying your blood. There are two kinds of dialysis: hemodialysis and peritoneal dialysis.
In hemodialysis, a dialysis machine and a special filter called an artificial kidney (dialyzer) clean your blood. To transfer blood to the dialyzer, a doctor will perform minor surgery on your arm to create access.
In a dialysis center, hemodialysis usually takes place 3 times per week for about 4 hours at a time. Home hemodialysis requires treatments more frequently, usually 4-7 times per week for shorter hours each time. Your doctor will decide the best place for hemodialysis based on your medical condition and your personal desires.
To bring your blood into the dialyzer, the doctor needs to make an access, or entrance, into your blood vessels. This is done with minor surgery, usually to your arm.
In peritoneal dialysis, the inside lining of your belly acts as a natural filter. Wastes are taken out by means of a cleansing fluid called dialysate after a catheter is placed in your belly by surgery. The cleansing fluid is washed in and out of your belly in cycles.
There are two kinds of peritoneal dialysis:
Continuous Ambulatory Peritoneal Dialysis (CAPD) which is continuous and machine-free. It takes place while you go about your normal daily living. You place cleansing fluid into your belly and later drain it when the cycle is done. This usually takes place 3-5 times each day.
Automated Peritoneal Dialysis (APD) is done with a machine called a cycler that delivers and drains fluids while you’re asleep.
Patients on dialysis are generally advised to increase their protein intake and limit potassium, phosphorus, sodium, and fluid in their diet. Patients with diabetes or other health conditions may have additional diet restrictions. For example, that means you should eat more chicken and eggs but season your food with something other than salt.
Be careful not to eat too much dairy, and stay away from spinach, lentils, potatoes, and other foods high in potassium. Also stay away from chocolate, nuts, and seeds as well as other foods high in phosphorous.
While it’s important to drink water throughout the day, be sure not to drink too many fluids (or eat foods with high water content). While you’re on dialysis, fluids can build up between treatments and lead to high blood pressure, swelling, and even heart failure.
Your healthcare providers will monitor your treatment with monthly lab tests to make sure you get the right amount of dialysis and your dietary goals are on target.
Transplants are safe surgeries, but not everyone can get a kidney transplant because there has to be a kidney available and you have to be in good health before going into the surgery.
The problem with transplants is that the body will often try to “reject” your new organ because it doesn’t recognize it. This is why post-transplant, you will have to take immunosuppressants for the rest of your life.
The American Kidney Fund recommends that patients going through dialysis or a kidney transplant find a counselor or a person they trust to speak to. Counseling is another layer of treatment that can help you feel more comfortable with your diagnosis and learn how to live with kidney failure.
Patients should also get plenty of exercise, eat healthily, and largely continue to live their lives the same way they did before their diagnosis.
While you don’t always have the option, patients who get a new kidney from a living donor typically live 5-10 years longer than people who get a new kidney from a recently deceased donor. Plus, you’re often able to have your transplant much sooner if you get a direct donation from a generous friend or relative instead of joining the kidney waitlist.
Medicare pays the full cost of care for your kidney donor. You and your donor don’t have to pay a deductible, coinsurance, or other costs for your donor’s hospital stay.
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