Today in the United States, there are close to 790,000 people living with end-stage renal disease (ESRD). Over 71 percent of them are currently on kidney dialysis and 29 percent have had a kidney transplant.
ESRD, also referred to as acute or chronic kidney failure, occurs when the kidneys can’t filter waste from the body adequately, usually at less than 15 percent of the normal level. Some of the more common symptoms of ESRD include:
- Feeling extremely fatigued
- Swelling in the lower extremities
- Loss of appetite
People who have ESRD need to undergo regular kidney dialysis treatments. These treatments filter impurities from the blood, so they don’t build up and cause illness or death. Dialysis helps maintain proper levels of chemicals and nutrients in the blood, helps maintain proper blood pressure levels, and sustains life until a patient can have a successful kidney transplant.
Why does Medicare cover ESRD?
ESRD is a life-threatening medical condition, so it’s fortunate that the United States Congress passed legislation in 1972 creating the End Stage Renal Disease Program through Medicare. Since then, people who have stage five chronic kidney disease and qualify for Medicare because of their work history have access to Medicare insurance coverage even if they haven’t reached the age of 65.
How do you qualify for Medicare if you have ESRD?
If you’ve been diagnosed with ESRD, you don’t have to wait to enroll in Medicare if all of the following conditions apply:
- Your kidneys no longer function
- You require regular dialysis treatments, or you’ve had a kidney transplant
- You meet the required amount of time working based on Social Security, Railroad Retirement Board, or government employee regulations; or you’re eligible for benefits from Social Security or RRB; or you’re the spouse or dependent child of someone who meets one of the above requirements.
If you meet these requirements, you are eligible to enroll in Original Medicare Part A (hospital insurance) and Part B (medical insurance). You must be enrolled in both parts to get full Medicare benefits covering dialysis and kidney transplant services.
If you’re already undergoing dialysis when you enroll in Medicare, your coverage begins the first day of the fourth month of treatments, which means you may qualify for retroactive coverage. If you don’t enroll in Medicare as soon as you’re eligible with ESRD, you may get retroactive coverage that extends up to 12 months before you sign up for Medicare insurance.
If you aren’t 65 and you’re enrolled in Medicare because of ESRD, your coverage ends either 12 months after the month you end dialysis treatments or 36 months after the month of a kidney transplant. You can enroll in Medicare again if you begin dialysis again, get a kidney transplant within 12 months after initially stopping dialysis, or you get another kidney transplant within 36 months of the initial transplant.
How does Medicare cover dialysis?
Original Medicare Part A covers dialysis treatments if your physician admits you to a hospital as an inpatient. Original Medicare Part B pays the dialysis facility you use to provide you with the following services and supplies:
- Nursing services from registered nurses, LPs, technicians, social workers, and dietitians
- Equipment and supplies that are reasonable and medically necessary for dialysis either at the facility or in your home
- Injectable, intravenous drugs, and some oral drugs
- Lab tests
- Training for in-home dialysis
- Miscellaneous services like heart monitoring, oxygen, etc. that you get during dialysis
Do Medicare Advantage plans cover ESRD?
If you qualify for Medicare coverage due to ESRD, you can choose to enroll in Original Medicare Parts A and B or a Medicare Advantage (Part C) plan. All Part C plan providers are required by federal law to provide at least the same benefits covered by Original Medicare Parts A and B.
However, depending on your Part C plan, you may be required to use medical facilities, hospitals, physicians, health care providers, and medical suppliers who are listed on your plan’s network of providers to be eligible for full coverage.