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End-stage Renal Disease (ESRD)

End-stage Renal Disease (ESRD) is one of the chronic conditions with special Medicare enrollment rights.

End-stage Renal Disease (ESRD)

What is ESRD per Medicare?

End-Stage Renal Disease (ESRD) is a chronic medical condition in which the kidneys of a person cease functioning on a permanent basis leading to the need for regular dialysis or a kidney transplant.

How does having ESRD impact my Medicare benefits?

If you have ESRD, you are eligible for Medicare irrespective of age. You may also qualify for support programs like Medicaid and be eligible to join a Special Needs Plan (SNP) if the right one is offered in your area.

Can I enroll into Medicare sooner if I have ESRD?

Yes, if you have ESRD you can enroll into Medicare irrespective of age. There may be a 1-3 month delay in starting to receive full benefits.

Do I need to enroll in a Special Needs Plan? Are there any ESRD-specific plans?

Yes, there are Special Needs Plans (SNPs) which are targeted towards those who have ESRD. However, such a plan may or may not be available in your area.

Starting in 2021, those with ESRD can enroll into any Medicare Advantage Plan, even if it is not an ESRD-dedicated SNP. MA Plans may have different costs and restrictions so make sure you understand the coverage offered by a plan. You may also want to ensure that your dialysis facility is part of the MA Plan's network.

Can I go to any dialysis facility?

You have to go to a Medicare or Plan approved hospital for inpatient dialysis or a Medicare or Plan certified facility for outpatient dialysis. If you are planning self-dialysis at home, you should be trained by a Medicare-certified dialysis facility.

I am already on Medicaid and have ESRD. Now what? Who pays for what?

Between Medicare and Medicaid, Medicare pays first. If you are a dual eligible, you would generally have broad coverage for any health condition, including ESRD.

You may also want to look at Special Needs Plans (SNPs) which may be offered in your area and enroll in one best suited for your needs.

How does having ESRD impact my Medicare costs?

Your Medicare costs depend upon your Plan, its network and cost-sharing structure.

Inpatient and Outpatient dialysis is covered in typical fashion where you are responsible for deductibles and coinsurance. Same applies to self-dialysis, including training and supervision. Note that Medicare Advantage Plans cannot set cost-sharing for either outpatient dialysis or immunosuppressant drugs higher than the beneficiary responsibility under default Medicare.

Medicare also provides coverage for a kidney transplant, including care for the kidney donor.

                                                                                                                                                  

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Last Updated: 01-10-2021