If you are diagnosed with End-Stage Renal Disease (ESRD), you may be eligible for Medicare, regardless of your age.
It’s one of a handful of medical conditions that allow individuals to qualify for Medicare prior to turning age 65, along with blindness and amyotrophic lateral sclerosis (Lou Gehrig’s Disease).
If you’ve been diagnosed with ESRD and you’ve met the other requirements to qualify for Medicare, know that you have resources available to help you get the care you need.
Eligibility for Medicare ESRD Benefits
To qualify for Medicare under the ESRD provisions, you must meet the following criteria:
- Be diagnosed with ESRD by a doctor
- Have kidneys that no longer function properly
- Need regular dialysis or have had a kidney transplant
- Meet one of the following work history requirements:
- Have sufficient work history under Social Security, the Railroad Retirement Board (RRB), or as a government employee
- Be eligible for or receiving Social Security or Railroad Retirement benefits
- Be the spouse or dependent child of someone who meets the work history requirements
- Apply for Medicare enrollment, as it is not automatic for ESRD patients
Medicare ESRD Considerations
There are a few things to consider when seeking Medicare coverage for ESRD:
- Medicare coverage usually begins on the first day of the fourth month of dialysis treatments. So you’ll want to maintain your current workplace or private insurance coverage or health sharing membership until then.
- Coverage can start earlier if you participate in a home dialysis training program.
- If you’re a kidney transplant recipient, Medicare coverage can begin the month you’re admitted to a Medicare-approved hospital for the transplant.
- You must enroll in both Medicare Part A and Part B to get full benefits for kidney transplant services.
- As of 2021, you can also enroll in Medicare Advantage plans if you choose, as long as you have ESRD.
Although ESRD patients are eligible for Medicare regardless of age, enrollment is not a given. Contact your local Social Security office to apply, or reach out to a MedigapAdvisors Personal Benefits Manager to help answer questions and guide you through the process.
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Coverage for Dialysis, Kidney Transplants, and Immunosuppressive Drugs
Medicare covers most kidney dialysis and kidney transplant services, as well as immunosuppressive drugs.
Here’s what you need to know about what’s covered, when.
Dialysis
If you’ve been diagnosed with ESRD, it’s very likely that you’ll need dialysis at some point.
Medicare Part A and Part B both cover dialysis services, but in different contexts. Part A covers inpatient dialysis in a hospital, while Part B covers outpatient dialysis at Medicare-certified dialysis facilities or at home.
Coverage applies to ESRD patients of any age who qualify for Medicare based on their diagnosis and includes:
- Outpatient dialysis treatments
- Home dialysis training
- Home dialysis equipment and supplies
- Certain medications related to dialysis treatment
- Laboratory tests
Medicare covers up to three hemodialysis treatments per week, unless there is medical justification for more.
Medicare Inpatient vs Outpatient Dialysis: What You Need to Know
You need to be enrolled in both Medicare Part A and Part B to receive full dialysis benefits, and the specifics vary depending on where the service is provided:
- Inpatient Dialysis is covered by Medicare Part A when you’re admitted to a hospital. After meeting the Part A deductible ($1,632 in 2024), Medicare covers the cost of dialysis or kidney transplants.
* Note: You may have to pay hospital coinsurance if the length of your stay exceeds your benefit period.
- Outpatient Dialysis is covered primarily by Medicare Part B, which covers outpatient dialysis treatments at Medicare-certified dialysis facilities or at home.
After meeting the Part B yearly deductible ($240 in 2024), you typically pay 20% coinsurance for each dialysis session. This covers equipment, supplies, lab tests, and most dialysis medications. Medicare pays the remaining 80% of the Medicare-approved amount.
However, if you have Medigap insurance (Plan G or N) or the Medi-Share 65+ health sharing plan, you won’t have to pay the 20% coinsurance. The best time to sign up for these plans are as soon as you’re eligible. With Medi-Share 65+, you can sign up as soon as you turn 65. With Medigap plans, you may be able to purchase a Medigap plan under age 65, depending on your state.
We’ll discuss both inpatient and outpatient dialysis below.
However, the important thing is that you contact a MediGap Advisors Personal Benefits Manager as soon as you can after receiving an ESRD diagnosis to make sure you’re eligible and to get signed up for benefits as soon as possible.
Otherwise, that 20% coinsurance under Part B can really add up!
Medicare and Kidney Transplants
If you need a transplant while a Medicare beneficiary, you should understand what the different parts Medicare covers and don’t cover.
Medicare Part A covers:
- Inpatient services in a Medicare-certified hospital
- Kidney registry fee
- Laboratory and other tests to evaluate the patient’s medical condition and potential kidney donors
- Costs of finding a suitable kidney for transplant if there’s no living donor
- Full cost of care for the kidney donor, including care before, during, and after surgery
- Any additional inpatient hospital care for the donor in case of complications from surgery
- Blood (whole units of packed red blood cells, blood components, and processing costs)
Medicare Part B covers:
- Doctors’ services for kidney transplant surgery, including care before, during, and after the surgery
- Doctors’ services for the kidney donor during their hospital stay
- Immunosuppressive drugs (transplant drugs) in certain circumstances, if Medicare paid for the transplant
- Blood (if a transfusion is needed)
Medicare will only cover kidney transplants performed in Medicare-certified hospitals, and patients typically pay 20% of the Medicare-approved amount after meeting the Part B deductible.
Medicare covers the donor’s hospital costs at 100%, with no deductible or copayment required from the recipient or donor. Coverage for ESRD patients typically continues for 36 months after a successful kidney transplant.
Immunosuppressive drugs are covered, and can be extended beyond the typical 36-month period under certain conditions.
*Coverage may differ for those enrolled in Medicare Advantage plans, so make sure to check your plan for more information.
The Medicare Immunosuppressive Drugs Program (Part B-ID).
Prior to January 2023, kidney transplant recipients who received Medicare due to ESRD rather than age or disability lost coverage for immunosuppressive medications 36 months after the transplant.
This created financial hardships for many patients, causing them to ration their medication, or stop taking it altogether!
But skipping these vital medications increases the risk of transplant failure and the return to dialysis. Which cost both beneficiaries and the Medicare system a lot more money in the long run.
Fortunately, as of January 1, 2023, Medicare now provides lifetime coverage for immunosuppressive drugs for kidney transplant recipients, regardless of age, through a new benefit known as Medicare Part B Immunosuppressive Drug Coverage (Part B-ID).
Part B-ID coverage is available to individuals who do not have other forms of public or private health insurance that cover immunosuppressive drugs.
Note: If you are under the age of 65 and have Medicare only because of ESRD, your coverage is not indefinite. Your coverage coverage will end:
- 12 months after the month you stop dialysis treatments
- 36 months after the month of your kidney transplant
Coverage may resume if you meet certain conditions, so make sure you are clear on your plan benefits.
Again, if you need help, or have any questions you need answered about your Medicare coverage and strategy, you can contact a Personal Benefits Manager to arrange a free individual consultation.
Eligibility for Medicare Part B-ID
To qualify for this indefinite coverage of immunosuppressive drugs under Medicare Part B-ID, you must meet the following criteria:
- Have received a kidney transplant from a Medicare-approved facility
- Do not have Medicaid
- Medicare coverage under Part A has ended
- Do not have other public or private health insurance (e.g., Medicaid, Veterans Affairs, TRICARE, or employer-based health plans) with immunosuppressive coverage
*NOTE: Medicare Part B-ID only covers immunosuppressive drugs related to your kidney transplant!
No other medical items or services, including routine medications or doctor’s visits, are included in this benefit.
Out-of-Pocket Costs and Supplemental Coverage
Medicare Part B-ID operates under traditional Medicare Part B rules, meaning you may still face 20% coinsurance costs for your immunosuppressive medications unless you have additional supplemental coverage.
Medicare Supplement plans (Medigap Plans), or Medi-Share 65+, can help cover out-of-pocket expenses making it easier to manage the cost of medications.
If you’re considering Medigap plans, it’s important to understand that medical underwriting may apply if you’re enrolling for the first time post-transplant. That means if you’re outside of your guaranteed enrollment period, you could be turned down for coverage. However, if you’re already enrolled in a Medigap plan, coverage for immunosuppressive drugs under Part B-ID will still apply.
Can I Join a Medigap Plan Prior to Turning 65 If I Have ESRD?
Not every state allows you to sign up for a Medigap plan prior to turning 65. However, Medigap coverage may be available to you before turning 65 if you live in one of these states:
Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Vermont, Wisconsin.
Contact a Personal Benefits Manager to enroll.
Medi-Share 65+ Health Sharing For ESRD Patients
Medi-Share 65+ is an option for those over 65, and can be beneficial as well. Medi-Share 65+ is not health insurance, it is a health sharing alternative that can help save money with overall costs.
There may be a six-month waiting period before sharing can begin, but this waiting period can sometimes be waived under certain circumstances, such as if you have prior coverage.
Medicare Advantage Plans for ESRD
In addition to Medigap plans, Medicare Advantage Special Needs Plans (SNPs) are available for individuals with ESRD.
These plans are tailored to meet the specific needs of patients, often offering comprehensive care that includes prescription drug coverage, doctor visits, and additional services designed to provide a more streamlined approach to care.
While Medicare Advantage plans can be appealing due to their additional benefits, they typically restrict coverage to network providers. So make sure your transplant doctors and hospital are in-network before enrolling. You should also understand your plan’s Maximum Out-Of-Pocket limits, and how they interact with your plan deductibles and coinsurance costs.
Additional Considerations
There are some costs that Original Medicare by itself does not cover, such as transportation costs to a transplant facility and prescription drugs (not counting the immunosuppressive drugs following a kidney transplant, which are included under Medicare B-ID.
This is where a Health Savings Account (HSA) can help!
If you have money in your HSA, you can use those funds to pay for transportation costs, including trips to dialysis facilities, tax-free. With a letter of medical necessity from your doctor, you can also use HSA funds to cover medically necessary vitamins, supplements, and durable medical equipment.
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Take Good Care of Yourself
There’s a lot to understand about getting the health care you need if you’ve been diagnosed with ESRD.
Enrolling in Medicare can help, ensuring access to services you may need to improve your health, such as dialysis, kidney transplants, and immunosuppressive drugs.
Supplemental plans like Medigap or Medi-Share 65+ can help even more, or you may want to consider Medicare Advantage Special Needs Plans designed for ESRD patients.
If you’re not sure which option is right for you, reach out for help!
A Personal Benefits Manager can take into consideration your unique situation, and help you compare details to get the best plan at the best cost, leaving you free to focus on healing and recovery.
For Further Reading:
Leslie Alford is a Personal Benefits Manager at MediGap Advisors. Leslie has a passion for bringing clarity to those confused about Medicare. She is an authority on Medicare, Medicare supplement plans, Medicare Advantage plans, and Part D prescription drug plans. Read more about Leslie on her Bio page.