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Medicare Coverage of End-Stage Renal Disease (ESRD)

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Medicare Coverage of End-Stage Renal Disease (ESRD)

Monday, February 26, 2018 12:40 PM

 Medicare Coverage of End-Stage Renal Disease (ESRD)

Americans of all ages, even those under the age of 65, with End-Stage Renal Disease (ESRD) may be eligible to receive Medicare benefits through the Medicare End-Stage Renal Disease Program. Learn more about ESRD and Medicare coverage options below.

What is End-Stage Renal Disease (ESRD)?

According to the U.S. Renal Data System Annual Data Report, chronic kidney failure, also called end-stage renal disease, or ESRD ("renal" is another word for kidney), affects almost 650,000 people per year in the United States. Often progressing slowly over a period of years, kidney failure is measured in five stages - and ESRD is the final stage when kidneys no longer function on their own. The job of healthy kidneys is to filter waste and fluids from building up in the body. However, when kidneys fail, patients must undergo lifelong dialysis treatments to replace the kidney’s filtering function. The other choice for an ESRD patient, if eligible, is a kidney transplant, which requires a donor match, major surgery, and a lifetime of medications to prevent rejection.

ESRD and Original Medicare coverage

ESRD Medicare recipients can qualify for health care coverage through Original Medicare (Part A and B) if: 

  • Their kidneys no longer work
  • Regular dialysis is needed, or they’ve had a kidney transplant
  • One of the following apply:
    • They’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee
    • They’re already getting or are eligible for Social Security or Railroad Retirement benefits
    • They’re the spouse or dependent child of a person who meets either of the requirements listed above

Does Medicare cover kidney dialysis?

Medicare Part A (Hospital Insurance) may cover or pay part of the costs for inpatient dialysis treatments at a Medicare-approved hospital.

Medicare Part B (Medical Insurance) may cover part of the costs for certain self-dialysis drugs, a variety of equipment, supplies, and services, including self-dialysis support services and training from a Medicare-certified dialysis facility.

Does Medicare cover a kidney transplant?

Medicare Part A (Hospital Insurance) may cover or pay part of the costs for transplant services in a Medicare-approved hospital for inpatient services, blood, lab tests, the kidney registry fee, and kidney donor-related costs.

Medicare Part B (Medical Insurance) may cover part of the costs for doctor’s services that accept assignment for kidney transplant surgery, a limited period of transplant drugs, and blood.

Please note: This is not a complete list of coverage. Contact your Medicare provider or visit for specific information about tests, items, or services covered by your health insurance plan.

ESRD and Medicare Advantage Plans 

Generally, ESRD Medicare recipients can only enroll in a Medicare Advantage Plan (MA) under the following circumstances:

  • They are already in a Medicare Advantage Plan when they develop ESRD
  • They are already getting health benefits (e.g., through an employer health plan) through the same organization that offers the Medicare Advantage Plan
  • They had ESRD, but have had a successful kidney transplant, and still qualify for Medicare benefits (based on age or a disability)

ESRD Medicare recipients may qualify for a Medicare Special Needs Plan (SNP), a type of Medicare Advantage Plan (like an HMO or PPO), if one is available in their area.

ESRD and Prescription Drug Plans

Original Medicare (Part A and Part B) does not cover prescription drugs. Therefore, ESRD Medicare recipients needing prescription drug coverage must join a plan run by a private insurance company approved by Medicare. ESRD Medicare recipients can generally enroll in a stand-alone Medicare Prescription Drug Plan (PDP) that may cover prescription drugs. They may also qualify for a Medicare Special Needs Plan (SNP), a type of Medicare Advantage Plan, that provides prescription drug coverage (MA-PD).

ESRD and Medigap

The Medicare program helps with the cost of health care for ESRD patients, but it doesn’t cover all medical expenses or the cost of most long-term care. Purchasing a Medicare Supplement Plan (Medigap), sold by private companies, can help pay for some of the health care costs that Original Medicare doesn't cover, including copayments, coinsurance, and deductibles. However, ESRD Medicare recipients can only buy a Medigap plan, if it’s available in their state. Federal law does not require all states to sell to people under 65 with ESRD.

To find out if Medigap is available in your state, compare Prescription Drug Plans, and learn more about eligibility for Medicare Advantage Plans, contact one of our experienced, licensed sales agents at (888) 815-3313 – TTY 711.

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Last Revised 11/15/2017