Navigating ESRD and Medicare

You may know that US citizens and permanent residents become eligible for Medicare around their 65th birthday. Did you also know that certain situations, like dialysis or a kidney transplant, may qualify you for Medicare early? Or that when you’re diagnosed with end stage renal disease (ESRD), you can keep your commercial insurance for 30 months while using Medicare as a backup?

Know the basics about Medicare:

Medicare is a health insurance program that is managed by the federal government, designed to provide low-cost healthcare.
Many people become eligible in the 7-month timeframe around your 65th birthday called the Initial Enrollment Period.
During Initial Enrollment, you can enroll in Medicare Part A and Part B, and choose other types of private Medicare insurance based on eligibility—without having to take a health exam.
Some people may become eligible for Medicare early based on certain health circumstances, like ESRD.

WHAT TO REMEMBER

It’s important to keep your current insurance while you learn more about your coverage options. Keep up with your premiums while you compare benefits and decide how best to pay for your ESRD treatments and prescriptions

With a diagnosis of ESRD, Medicare eligibility can change

Kidney failure happens at end-stage renal disease, which is stage 5 of chronic kidney disease (CKD). It’s the point at which you need a kidney transplant or dialysis to replace kidney function. Medicare is available to most people who are undergoing either of these treatments, at any age.

It’s important to understand all of your options for transplant or dialysis coverage before making any kind of change in insurance, so you can make the best decisions for your unique situation. Different coverage plans may cover different needs, and there are many aspects of treatment to consider in addition to ongoing treatment, including medications, supplies and testing.

Who is eligible for ESRD Medicare enrollment?

Once you’ve been diagnosed with ESRD, you’re eligible for ESRD Medicare as long as you meet 1 of the 3 following requirements:

You have collected enough work credits (usually 10 years of work) under Social Security or the Railroad Retirement Board (RRB).
You are already receiving, or are eligible for, Social Security or RRB benefits.

NOTE: If you received Social Security Disability or certain RRB benefits for 24 months prior to being diagnosed with ESRD, you are already enrolled in Medicare and don't have to reapply—though you do have the option to reapply if you want to make changes to your plans.
You are the spouse or child of someone who has met either of the requirements above.

What steps should I take if I’m already on Medicare and my kidneys fail?

If you're already receiving Medicare coverage, you have the option to re-enroll as an ESRD Medicare recipient. There are a couple of reasons you might want to do this:

If you only have Part A, you can use this opportunity to enroll in Part B without paying late enrollment fees.
If you have Part A and Part B, and you're paying late enrollment fees for your Part B coverage, you can enroll again based on ESRD and have your late fees removed.

Should I consider keeping my insurance instead of switching to Medicare?

Sometimes, Medicare is not the most cost-effective option. When deciding whether or not to keep your current plan or sign up for Medicare, it’s important to look at all the possible costs associated with your insurance and with Medicare, so you can make an accurate comparison.

Be sure to look at the details of your co-payments, out-of-pocket costs, deductibles and medication costs. Sometimes, Medicare may seem like the less expensive plan on the surface, though the coverage may be less than your current insurance and medications may not be covered—which means, for some people, Medicare could actually end up costing more. Remember, you don't have to join Medicare if you don't want to and it's important to make the decision that's right for you and your finances.

When would my ESRD benefits with Medicare begin?

Your Medicare benefits are triggered by when you start treatment.

If you require a transplant surgery:
Medicare coverage usually begins when you are admitted to the hospital for transplant surgery. If you require transplant-related care, coverage can begin up to 2 months prior to surgery.

If you're starting dialysis:
Your benefits will begin in the fourth month of dialysis. However, you can get your benefits earlier. If you choose home dialysis, or if you start a class on how to perform home dialysis while you receive treatment at the dialysis center, Medicare coverage may start in the first month of dialysis.

HOME DIALYSIS MAY QUALIFY YOU FOR BENEFITS SOONER

Talk to your doctor about the benefits of home dialysis. Home dialysis can mean greater flexibility in treatment scheduling, fewer food restrictions, less medication and better results.

How long do my ESRD Medicare benefits last?

Medicare coverage ends 12 months after dialysis ends, or 36 months after a kidney transplant. If you need dialysis or another transplant after coverage ends, your coverage will start over with the full allotted coverage time. Medicare will keep covering you as long as you need dialysis or a kidney transplant.

Considering Home Dialysis Cost

Choosing to treat stage 5 chronic kidney disease (CKD) in the comfort of your own home can be more effective, give you more...

The Importance of Removing Excess Fluid

Healthy kidneys pull extra fluid out of your body and send it away in your urine. If you have kidney failure at stage 5 chronic kidney...

“Be active and keep going because we’re here for a reason.”

—Gloria, on dialysis since March 2013

Watch Gloria’s Story