A Guide to Medicare and End-Stage Renal Disease (ESRD)

Around 786,000 Americans suffer from End-Stage Renal Disease (ESRD), also known as End-Stage Kidney Disease (ESKD). Because the monthly cost of dialysis is too high for most Americans to manage, Medicare is available for ESRD patients to help make quality care more affordable. 

Many people are unaware that Medicare provides coverage for younger Americans with certain disabilities and conditions. Options for patients with End-Stage Renal Disease were even expanded in 2021. The Cures Act now allows Medicare beneficiaries with ESRD to enroll in Medicare Advantage plans, regardless of their previous coverage. 

You might be wondering if you’re eligible, when you can sign up, and what all of your options are. In this guide, we’ll go over just that to help you understand the ins and outs of Medicare for End-Stage Renal Disease patients.

Key takeaways:

• People with End-Stage Renal Disease (ESRD) are eligible for Medicare coverage to help cover dialysis and any other ESRD-related treatment and prescription drugs.

• ESRD patients can enroll in Original Medicare or Medicare Advantage—each has its own pros and cons.

• If you have ESRD, it’s best to work with a Medicare Advisor to choose a plan that meets your specific needs.

Eligibility criteria for ESRD and Medicare

While Medicare is generally meant for older Americans, younger ESRD patients can still be eligible if they meet the following conditions:

• Your kidneys are no longer functioning

• You’re in need of regular dialysis or a kidney transplant

• You meet one of the following criteria:

  • You’ve worked the required amount of time for Social Security, the Railroad Retirement Board, or as a government employee

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

  • You’re the spouse or dependent child of someone who meets one of the above criteria

If you’re on Medicare only because of ESRD, then you’ll become ineligible once you no longer meet the above requirements. Your Medicare coverage will end 12 months after you stop dialysis treatments or 36 months after a kidney transplant. 

What does Medicare cover for dialysis services and other ESRD-related treatment? 

The majority of people with ESRD rely on dialysis to remove waste and excess fluids from the kidneys. Some people may also get a kidney transplant. Medicare Part B covers dialysis and ESRD-related treatments, including:

• Services at a dialysis facility

• Drugs for dialysis (injectables included)

• Home dialysis equipment

• Home dialysis training program for family members, caregivers, and ESRD patients

• Doctor visits and lab tests

• Nutritional counseling if you had a kidney transplant or you have chronic kidney disease

Medicare Part A covers any hospital services you receive for ESRD, including kidney transplants.

Medicare Part D covers prescription drugs that aren’t used for dialysis. Make sure you enroll in a prescription drug plan that includes all the drugs you need to manage ESRD.

Choosing coverage for Medicare with ESRD

If you’re eligible for Medicare because of ESRD, then late enrollment penalties and coverage start dates work differently. In fact, if you don’t sign up right away, your coverage could apply for services received up to 12 months prior to the month you sign up—this is known as retroactive coverage. 

When you sign up for Medicare, you have two primary coverage options: Original Medicare or Medicare Advantage, and there are pros and cons to both.

Key Differences between Original Medicare and Medicare Advantage for ESRD:

• Medicare Advantage plans can come with additional benefits that aren’t covered by Original Medicare, including dental, hearing, and vision coverage.

• Medicare Advantage is often referred to as a “bundle option” because these plans often bundle Original Medicare (Part A and Part B) coverage with prescription drug coverage (Part D). 

• Original Medicare provides beneficiaries with more options for which doctors and specialists they can see—around 93% of doctors accept Original Medicare, while network sizes vary with Medicare Advantage.

• Without secondary coverage via a Medigap plan, Original Medicare doesn’t cap out-of-pocket costs. With Medicare Advantage plans, the out-of-pocket costs can vary, but cannot exceed $7,550 in a year for in-network, covered medical services. 

ESRD and Medicare Advantage plans

Given the bullet points above, people with ESRD should consider certain limitations to Medicare Advantage plans. Medicare Advantage plans have networks of providers and often require prior authorization for covered services—both of which could cause delays to the care you need. They also vary in their out-of-pocket costs, so there’s less predictability in your healthcare expenses.

That said, ESRD patients qualify for Chronic Conditions Special Needs Plans (C-SNPs). These are a type of Medicare Advantage plan that offer greater support and specialized care for people with chronic conditions.

Understanding costs of Medicare with ESRD

As with any insurance, costs will vary depending on the plan(s) you choose and the services you need. Medicare greatly reduces the cost of dialysis, regardless of which coverage you choose. It’s best to work with a Chapter Advisor to compare the costs of monthly premiums, copayments, deductibles, and coinsurance to determine the best plan available for your needs. We’ll help you maximize your benefits while minimizing costs to ensure quality care at the most affordable price.

When we search and compare available plans, we go the extra mile to ensure your preferred doctors and prescriptions are covered. We’re also with you every step of the way after we find the right plan to help with:

• Understanding what’s covered in your plan

• Finding in-network providers and scheduling appointments

• Filing claims and negotiating bills

• And so much more

Call one of our Advisors today at 855-900-2427 or schedule a time to chat to get your questions answered or enroll in Medicare.

Frequently asked questions