How To Get The Best ESRD Medicare: Plan Options & Tips

For people with kidney disease, Medicare can help cover essential services like dialysis and transplants—-but the rules are complicated. We can help you navigate the details.

We can also help you sort through your coverage options when you use the Insurify Medicare plan comparison tool. Enter your ZIP code to uncover plan options near you. Safe and secure searching lets you get the best price—try it today!

What Is ESRD?

End-stage renal disease ( ESRD ) is a health condition that causes a person’s kidneys to stop working permanently. People with ESRD require long-term dialysis or a kidney transplant to survive.

Medicare may be available for people with this serious condition even if they are younger than 65. ESRD Medicare covers a range of services to treat kidney failure as well as the usual covered healthcare services and items. But as is often the case with Medicare, the details can get complicated. ESRD Medicare was created after and separately from Original Medicare, so some of the rules are different.

What Is ESRD Medicare, and Am I Eligible?

ESRD may entitle you to Medicare even if you’re under 65. If you’re eligible, it’s your choice to enroll in Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).

Regardless of your age, you are eligible for Medicare if all of these apply:

• Your kidneys do not work,

• You need regular dialysis treatments or (have had) a kidney transplant, and

• One of the following applies to you:

• - - You’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee

  • You’re already getting or are eligible for Social Security or Railroad Retirement benefits

  • You’re the spouse or dependent child of a person who meets either of the requirements listed above

If you’re not sure about the amount of working time required for Medicare eligibility, you can contact the Social Security Administration ( SSA ) for more information. 1-800-772-1213 (TTY 1-800-325-0778) between 8:00 am and 7:00 pm., Monday through Friday.

If you get benefits from the Railroad Retirement Board, call 1 (877) 772-5772.

What Does ESRD Medicare Cover?

ESRD Medicare includes the same coverage as Original Parts A and B (if you choose to enroll in both), including the following care related to kidney disease:

• - - Kidney transplants

  • Inpatient dialysis

  • Outpatient dialysis from a Medicare-certified hospital or freestanding dialysis facility

  • Home dialysis training, sometimes called self-dialysis, from a dialysis facility, including:

  • Training for you and caregivers who will provide home dialysis

  • Home dialysis equipment and supplies

  • Medications related to treatment (medication is only covered when overseen by a doctor)

  • Immunosuppressant drugs after a kidney transplant, as long as you had Medicare Part A at the time of the transplant

It’s important to note that in order to receive the full benefits for certain dialysis and kidney transplant services, you’ll need both Medicare Part A and Part B.

In most states, there are agencies and state kidney programs that can help with the healthcare costs that Medicare doesn’t pay. If you need guidance about your coverage options, call your State Health Insurance Assistance Program (SHIP).

How Do I Apply for ESRD Medicare?

If you’re eligible for Medicare because of ESRD, you can enroll in Part A and Part B by logging into your account at SSA.org. If you qualify for Medicare based on prior railroad work, Social Security is still responsible for handling ESRD Medicare enrollment.

Your provider and/or dialysis center should send documentation to Social Security verifying that you have ESRD and stating your treatment needs.

You can enroll in Medicare Parts A and B (as long as you enroll in both at the same time) at any point during what’s called your 30-month coordination period, which begins the month you first become eligible for ESRD Medicare —even if you don’t enroll right then.

If you want to delay ESRD Medicare enrollment because you have other health insurance, you should turn down both Part A and Part B. If you enroll in Part A and delay Part B, you lose your right to enroll in Part B at any time during your coordination period. You will then have to wait to enroll in Part B until the General Enrollment Period, and you’ll probably face gaps in coverage as well as a late-enrollment penalty.

If you are unable to enroll yourself due to illness, a family member or other designated party can enroll for you.

When Will My Coverage Start?

This is a seemingly simple question with a complicated answer. (Welcome to Medicare!)

The start date of your ESRD Medicare coverage depends on a number of factors.

This is because eligibility for Medicare based on ESRD works differently than other types of Medicare eligibility. If you’re eligible for Medicare because of ESRD but don’t sign up right away, your coverage could start up to 12 months before the month you apply. This is called retroactive coverage.

If you’re on dialysis:

• You aren’t eligible to sign up for Medicare until the day you begin dialysis.

• For hemodialysis at a treatment center, Medicare coverage usually starts on the first day of the fourth month of your treatments. This four-month waiting period begins on your first month of dialysis, even if you haven’t signed up for Medicare yet.

• If you’re covered by a group health plan (such as through an employer), your ESRD Medicare coverage will still start the fourth month of dialysis treatments, and your group health plan may pay for the first three months of dialysis.

• For at-home dialysis treatment, whether peritoneal or hemodialysis, Medicare coverage can begin the first month of a regular course of treatments if:

• You participate in a home dialysis training program offered by a Medicare-certified training facility during the first three months of your regular dialysis.

• Your doctor expects you to finish home dialysis training and be able to do your own treatments.

If you’re having a kidney transplant:

• -Your Medicare coverage can begin the month you’re admitted to a Medicare-certified hospital for a kidney transplant (or for the care you need before your transplant) if your transplant takes place in that same month or within the next two months.

• If your transplant is delayed more than two months after you’re admitted to the hospital (for the transplant or for the care you need before the transplant), Medicare coverage can begin two months before your transplant.

When Does ESRD Medicare Coverage End?

Again, it depends.

If you have Medicare only because of permanent kidney failure, your Medicare coverage will end:

• 12 months after the month you stop dialysis treatments

• 36 months after the month you have a successful kidney transplant

Your ESRD Medicare coverage can resume if:

• You start dialysis again or get a kidney transplant within 12 months after you stopped getting dialysis.

• You start dialysis or get another kidney transplant within 36 months after the month of your kidney transplant.

Is Medicare the Primary Payer for ESRD Care?

This is another simple question with a complicated answer.

If you have insurance through a group health plan (GHP) like your or your spouse’s employer, that insurance plan will be primary (meaning it pays first) for the 30-month coordination period starting the day your dialysis begins. During this coordination period, your GHP coverage must pay first, and ESRD Medicare is the secondary payer.

Remember that you do not have to sign up for ESRD Medicare immediately if you have GHP coverage. But even if you have a GHP plan, you might still want to enroll in ESRD Medicare. Your healthcare will likely be very expensive, and Medicare might help cover your GHP cost-sharing responsibilities like deductibles, co-payments, and coinsurance.

After the 30-month coordination period, Medicare will pay first and your GHP will pay second.

If you enroll in ESRD Medicare at the start of your 30-month coordination period, Medicare automatically becomes the primary payer when that period is over.

If you do not have other insurance, ESRD Medicare will be primary as soon as you enroll.

If you have COBRA first and then enroll in ESRD Medicare, your employer can choose to end your COBRA coverage, but not all employers terminate your COBRA after you enroll in ESRD Medicare. It’s very important to talk to your employer before making enrollment decisions. If you have ESRD Medicare first and then qualify for COBRA, your employer is obligated to offer you COBRA coverage. Either way, COBRA coverage is primary during the 30-month coordination period, after which it becomes secondary.

What Will My Costs Be with ESRD Medicare?

Yet again, there is unfortunately no simple answer to this. It depends on what type(s) of coverage you have—a group health plan, ESRD Medicare alone, Medicare Advantage, and/or Medigap—as well as what services you get.

If you have a group health plan that’s primary, ESRD Medicare might help pay some of your cost-sharing responsibilities from your GHP during the coordination period.

With ESRD Medicare, you will be responsible for the cost-sharing portions of Original Medicare Parts A and B. This means that Original Medicare pays some of the cost of your services, and you pay the rest:

• For 2021, Medicare Part A (Hospital) is $1,484. You will have to pay this amount out of pocket before the Part A benefits kick in.

• Medicare beneficiaries are also generally responsible for a 20 percent coinsurance on Part B (Medical/ Outpatient ) services.

It’s important to note that ESRD Medicare won’t cover surgery or services you may need to prepare for dialysis before your Medicare eligibility begins. For example, Medicare won’t pay for surgery to create an access point for a dialysis machine.

Medicare will, however, pay for costs related to your kidney donor’s hospital stay and follow-up care. Neither of you will be charged or responsible for cost-sharing.

Here’s a breakdown of what Medicare pays and what you pay for ESRD healthcare services:

ESRD Coverage Options

Across the country, there are hundreds of options for ESRD coverage. The number of plan options available to you will depend on where you live. If you find that your area lacks options, consider checking nearby areas. For some, relocating to an area with better coverage options could create a better environment for healing.

If I Have ESRD, Can I Apply for a Medicare Advantage Plan?

As of January 2021, people with ESRD can choose between Original Medicare or a Medicare Advantage (MA) plan.

MA plans are a type of Medicare health plan sold by a private company that contracts with Medicare to provide all your Part A and Part B benefits. Most Medicare Advantage plans also offer prescription drug coverage.

If you join a Medicare Advantage plan with drug coverage, you’ll get your drug coverage through your plan, and you can’t enroll in a separate drug plan. Some Medicare Advantage plans also offer additional coverage, like vision, hearing, and dental benefits.

You’ll need to use healthcare providers who participate in the plan’s network and service area. Before you enroll in a Medicare Advantage plan, it’s important to check with your providers and the plan you’re considering to confirm that the providers you currently see (like your dialysis facility or kidney doctor) or want to see in the future (like a transplant specialist) are in the plan’s network.

If I Have ESRD, Can I Buy a Medigap Plan?

Medigap plans, which are supplemental Medicare policies that help cover the payment “gaps,” are not available in all states to ESRD patients under age 65. In states without Medigap for those individuals, they may not be able to purchase any other supplemental policy and will be responsible for paying all deductibles and coinsurance.

How Does Coverage for Prescription Drugs Work?

It depends on which Medicare plan(s) you have. If you have a Medicare Advantage plan, drug coverage may be included.

Otherwise, you can enroll in a stand-alone Medicare drug plan (called Part D ). You can enroll in a stand-alone Part D plan as soon as you are eligible for Medicare. In other words, you can enroll during your Initial Enrollment Period (IEP). Your IEP begins three months before the month of your 65th birthday and ends at the end of the third month after the month of your birthday.

Your prescription drug coverage will start the same time your Medicare coverage begins, or the first month after you make your request, whichever is later.

For people with ESRD Medicare, Part B covers transplant drugs after a covered transplant and most of the drugs you get for dialysis. However, Part B doesn’t cover prescription drugs for other health conditions unrelated to your kidney disease. Medicare Part D can help you with the costs of drugs not covered by Part B.

Is There a Medicare Special Needs Plan (SNP) for ESRD?

Special Needs Plans are Medicare Advantage plans that coordinate care for people who have certain chronic conditions, live in an institution, or have both Medicare and Medicaid. SNPs customize benefits, provider networks, and drug formularies to meet the specific needs of the groups they serve. All SNPs include Medicare Part A, Part B, and prescription drug coverage ( Part D ).

But SNPs are not available everywhere, and the availability of different Medicare SNPs in a given area can change from year to year. This is because SNPs are sold by private insurance companies who can choose where to do business and whether to participate in Medicare.

In some areas, there are SNPs for ESRD. To be eligible, you must already be enrolled in Medicare Parts A and B and live in the plan’s area. You can look for and compare SNP plans in your area here. Follow these steps:

• - 1. 1. Enter your ZIP code.
  2. Use the filters on the left side to filter by “Plan Type.”
  3. Select “SNP” to see only SNP plans.

Keep in mind that Special Needs Plans are not available everywhere. If you don’t see the option to filter by SNP, then these plan types are likely, not available in your county.

FAQ: ESRD Medicare

ESRD Medicare Can Improve Your Access and Lower Your Healthcare Costs

The ins and outs of this special Medicare category are complicated, but you’re not alone in figuring it out.

Talk to your healthcare provider, contact your State Health Insurance Program for guidance, or talk to a licensed Medicare insurance agent for free when you use the Insurify plan comparison tool. You can also find help in your area through the “Find Someone to Talk To” tool on the right side of Medicare.gov web pages.