ESRD Medicare Coverage (Chronic Kidney Disease)
ESRD, or end-stage renal disease (kidney failure), is a unique condition that Medicare covers a little differently from other diagnoses. You may be eligible for ESRD Medicare coverage even if you are not yet 65! Medicare covers treatments like kidney transplants and dialysis.
Click the links below to read about ESRD Medicare coverage:
- ESRD Medicare Eligibility and Enrollment
- Does Medicare Cover Dialysis and Kidney Transplants?
- What is End Stage Renal Disease?
- End Stage Renal Disease Treatment Options
- Get the Best ESRD Medicare Plan
ESRD Medicare Eligibility and Enrollment
To be eligible for ESRD Medicare coverage without being at least 65 years old, you must have an official end-stage renal disease diagnosis and you must qualify for SSDI (Social Security Disability Insurance) or Social Security retirement benefits/railroad retirement benefits based on your work history.
- 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
Does Medicare Cover Dialysis and Kidney Transplants?
Yes! Medicare covers hospital inpatient dialysis and outpatient dialysis from free-standing facilities and hospitals that work with Medicare. Medicare can also cover home dialysis training for you and your caregivers as well as related equipment and medications. 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 want a C-SNP. CSNPs, or Chronic Special Needs Plans, are a type of Medicare Advantage plan for people with chronic healthcare conditions like chronic kidney disease.
Keep in mind that you will have to meet your deductible before Medicare Part A and B cover your dialysis treatments. In 2019, the standard Part A (hospital treatments and services) deductible is $1,364. The standard 2019 Part B (doctor visits and home health) deductible is $185. Therefore, before your Medicare coverage kicks in, you’ll have to spend $1,364 on hospital services and $185 on doctor and home health services. 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.
If you have a kidney transplant, you will have to take immunosuppressants for the rest of your life so that your body doesn’t reject the new kidney. If end-stage renal disease is the only reason you have Medicare and you had it at the time of your transplant, Part B will cover your immunosuppressants. If your transplant is successful, your Medicare coverage will end three years after the transplant. If you have Medicare for another reason (age, disability, etc.), you’ll need a Part D or Medicare Advantage plan to cover your immunosuppressant prescription.
What is End Stage Renal Disease?
ESRD is the last stage of chronic kidney disease, a condition in which the kidneys do not function properly. 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.
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 itching, muscle cramps, loss of appetite, nausea, changes in your urine cycle, swollen feet and ankles, and trouble sleeping and catching your breath. Some people may also experience stomach and back pain, diarrhea, fevers, nosebleeds, and even rashes.
The 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.
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End Stage Renal Disease 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 a process in which a machine is hooked up to you to perform the functions that your kidneys should be performing for you: separating your fluids and purifying your blood. 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. They also recommend that patients get plenty of exercise, eat healthily, and largely continue to live their lives the same way they did before their diagnosis. 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 (learn how to be a kidney donor here).
It’s always a good idea to speak to a nutritionist, dietician, or doctor you trust. ESRD patients should eat a lot of protein and limit potassium, phosphorous, sodium, and fluids. 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.
Get the Best ESRD Medicare Plan
Unfortunately, not all private plans offer coverage for those with an ESRD diagnosis. If you qualify for a Medicare Advantage or Medicare Supplement plan, we can help you select the best one for end-stage renal disease coverage. Send us a message or give us a call during business hours at 844-431-1832.