Most people in the United States qualify for enrollment in Medicare on the basis of age. However, several health-related exceptions exist that allow for early enrollment, including if a person has end stage renal disease (ESRD).
A person with ESRD may require special medical care and support, particularly when it comes to undergoing dialysis to maintain their health.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
ESRD, also known as kidney failure, is a chronic medical condition in which the kidneys work at less than 10–15% of their normal capacity. Although there is currently no cure for chronic kidney disease, some therapies can help control symptoms, reduce complications, and slow the disease’s progression.
Some treatment options, such as dialysis and kidney transplants, carry the risk of potentially serious complications.
Federally funded Medicare covers various aspects of healthcare in different parts of the program.
- Medicare Part A provides coverage for hospital and long-term care.
- Medicare Part B covers medical healthcare, such as doctor’s visits, some immunizations, and durable medical equipment, such as a wheelchair or crutches.
- Medicare Part C, also known as Medicare Advantage, is an optional alternative to original Medicare (Part A and Part B). Private insurance companies offer Advantage plans, which must provide at least the same basic benefits as original Medicare. Additional benefits may include hearing, vision, and dental coverage.
- Medicare Part D offers coverage for prescription drugs. The federal government requires that a person enrolled in Medicare has either a Part D plan or other prescription drug coverage.
Each Medicare part may provide different insurance coverage for a person with ESRD.
Medicare Part A
Medicare Part A traditionally covers hospitalizations and some surgeries, such as kidney transplant surgery. If a person qualifies for Medicare coverage based on their age (65 years and older) and undergoes dialysis, Part A will cover the costs.
The exception is when a person is younger than 65 years and starts dialysis because there is a 4-month waiting period before Medicare benefits begin.
Medicare Part B
Medicare Part B covers doctor’s visits, including consultations with nephrologists, who are doctors specializing in treating kidney disorders.
If a person qualifies for a kidney transplant, Medicare Part B will usually cover transplant-related medications that help stop the body from rejecting the transplant. Medicare Part B also usually covers the costs of dialysis medications, such as the fluids that the person receives during dialysis (known as dialysate).
Medicare Part C
Advantage plans include a specific type of plan called a Special Needs Plan (SNP) for people with certain conditions, such as ESRD, heart failure, and diabetes. According to the Kaiser Family Foundation, the number of SNPs has more than doubled since 2017, with 174 plans on offer in 2021.
SNPs usually offer expanded coverage for common dialysis medications and extend the availability of larger networks for dialysis facilities and doctors. They may also offer other benefits unique to ESRD treatments.
Medicare Part D
If a person with ESRD qualifies for Medicare, the government will require them to have prescription drug coverage that is equivalent to the basic Part D prescription drug plan.
As a person with ESRD may have additional chronic health conditions, such as diabetes or hypertension, they can check their Part D provider’s list of covered drugs — known as a formulary — to ensure that their plan provides the necessary medications.
A person with ESRD is eligible for Medicare if:
- their kidneys are no longer working
- they need regular dialysis
- they have a kidney transplant
If a person elects to receive dialysis treatments at a dialysis facility, their Medicare coverage will usually begin on the fourth month of dialysis.
However, if a person chooses a home dialysis training program that allows them to dialyze at home (known as peritoneal dialysis), their Medicare benefits may start as early as the first month they are on dialysis.
It is important to note that not everyone who requires dialysis can participate in peritoneal dialysis. A person will need to check with their doctor whether they qualify.
A person can also check the starting date of benefits by contacting Medicare or the Social Security Administration (SSA).
Once a person has received a diagnosis of ESRD, they can sign up for Medicare by contacting the SSA. They can do this by:
- using this search tool to find a local office
- finding more information online on the SSA website
- calling the national number at 800-772-1213
A person with an ESRD diagnosis can enroll in original Medicare (parts A and B). Although enrolling in Part B is voluntary, a person might wish to do so to get coverage for dialysis and kidney transplant services.
Some costs associated with Medicare include the following:
- Part A: If a person or their spouse has paid Medicare taxes for at least 40 quarters (about 10 years), they do not have to pay a premium for Part A. Otherwise, the premium depends on the total number of months for which the individual paid Medicare taxes, to a maximum of $471 per month. In addition, a person must pay the annual deductible of $1,484. Coinsurance ranges from zero upward.
- Part B: The Medicare Part B premium is $148.50 for individuals who make less than $88,000 per year or less than $176,000 if married filing jointly. After a person meets the $203 deductible, they are usually responsible for 20% of the Medicare-approved amount for medical services.
- Part C: Premiums for Advantage plans vary, with many providers offering zero-premium plans. However, there may be other costs, depending on the plan coverage and the use of in-network health providers and facilities. In 2021, the estimated average Advantage premium is $21 a month, according to the Centers for Medicare & Medicaid Services (CMS).
Learn more about choosing an Advantage plan here.
- Part D: Premiums for drug prescription plans vary depending on coverage. A person will usually pay a portion of the costs but may incur no costs for some generic medications.
Learn more about comparing prescription drug plans here.
A person with ESRD may also get help with healthcare costs, such as through employer insurance or Medicaid.
Federally funded Extra Help supports people with limited income and assets, helping them pay for some healthcare costs. The annual income limits are below $19,140 for an individual and below $25,860 for a couple, and assets must be worth less than $14,790 for an individual or $29,520 for a couple, according to the SSA.
Medigap is supplemental insurance that helps meet costs such as deductibles, copays, and coinsurances. Depending on a person’s policy, a plan may offer coverage for several expenses, including original Medicare’s out-of-pocket costs and some skilled nursing care costs.
Medicaid may offer help with costs for people from low income households with few resources, although the determining criteria vary among the different U.S. states.
A person with ESRD may qualify for Medicare before the age of 65 years. The federally funded program can help cover costs for dialysis and medications, although there may be out-of-pocket costs. Programs such as Medicaid may help with these costs.
If a person has questions about when they may qualify for Medicare, they should contact 800-MEDICARE (800-633-4227) or the SSA.