Medicare Coverage With End-Stage Renal Disease

One way to qualify for Medicare coverage is as the result of an End-Stage Renal Disease (ESRD) diagnosis, regardless of an individual’s age. As part of the End-Stage Renal Disease Treatment Choice (ETC) model, Medicare can cover medical expenses for individuals who are in late-stage kidney disease.

But what is ESRD, and how does Medicare apply to individuals impacted by this disease?

What Is End-Stage Renal Disease?

End-Stage Renal Disease (ESRD) is advanced chronic kidney disease, otherwise known as end-stage kidney disease or permanent kidney failure. With this disease, an individual’s kidneys fail to function independently. In order to survive, they must receive long-term dialysis or a kidney transplant.

ESRD impacts people of all ages, including children. Therefore, individuals diagnosed with ESRD can qualify for Medicare coverage even if they are younger than 65.

Medicare’s End-Stage Renal Disease Treatment Choice Model

The End-Stage Renal Disease Treatment Choice (ETC) model was finalized by the Centers for Medicare and Medicaid Services (CMS) in 2020. It improves access to health care for individuals with ESRD, who previously may have lost coverage for services or paid additional insurance premiums.

This treatment model protects people in kidney failure from losing or overpaying for their health coverage as they receive life-saving treatments. ESRD-based Medicare coverage varies depending on whether someone is insured by a group health plan or only Medicare.

Private Insurance & Group Coverage With ESRD

The ETC model forbids group health plan providers from

  • differentiating or limiting benefits,
  • terminating coverage,
  • or raising premium prices for individuals on the basis of an ESRD diagnosis.

If an individual is on group health plan coverage, they must enroll in Medicare within 30 months of their ESRD diagnosis. This 30-month window is called a coordination period. Based on this time frame, Medicare and private insurance work together differently.

During the first 30 months of an individual’s ESRD diagnosis, group health insurance pays first on an individual’s health care costs. Medicare then acts as a secondary payer and picks up the remainder of the costs for Medicare-approved services.

However, after 30 months the coverage switches. Medicare pays first, then the group health plan picks up the remaining costs secondary.

Once an individual enrolls in Medicare (during the 30-month coordination period), benefits apply at different times based on whether they receive dialysis or a kidney transplant.

Dialysis

If an individual receives dialysis, Medicare benefits begin during the fourth month of dialysis treatments in a Medicare-approved dialysis facility.

But learning to administer their own dialysis treatments at home can make their Medicare benefits apply sooner. Medicare will cover as early as the first month of dialysis if an individual:

  • Completes a home dialysis training program at a Medicare-approved facility
  • Begins (and expects to finish) home dialysis training
  • Gives self-dialysis treatments within first three months

For individuals who receive dialysis, Medicare stays in effect until 12 months after the last month of dialysis treatment.

Kidney Transplant

Medicare benefits apply during the same month that a Medicare-approved hospital admits an individual for either

  • a kidney transplant, or 
  • transplant-related services to prepare for a transplant scheduled within two months.

For transplant recipients, Medicare benefits apply until 36 months after the kidney transplant date.

Note: An individual may requalify for Medicare through the ETC model if they need additional dialysis or a transplant later. A separate 30-month coordination period applies in that case.

What Does Medicare Cover?

Treatments for ESRD include long-term dialysis and kidney transplant, but Medicare covers more than those services for impacted individuals. If someone qualifies for Medicare because of ESRD, Medicare covers all the same medical services—not just those associated with ESRD.

In all cases, though, Medicare only pays for approved services. For example, Original Medicare does not cover prescription drugs. Even individuals with ESRD would have to secure prescription drug coverage through another source (such as primary insurance, creditable coverage, a standalone drug plan, or a Medicare Advantage Prescription Drug plan).

Local Guidance for End-Stage Renal Disease (ESRD) Patients

If you or someone you know has been diagnosed with End-Stage Renal Disease (ESRD), our advisors can help with exploring health insurance options and finding the right coverage for your needs. RetireMEDiQ provides local answers to health insurance questions to individuals like you every day. Chat with one of our advisors by calling 1-866-921-6468 or emailing [email protected].

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