END STAGE RENAL DISEASE (ESRD)
End Stage Renal Disease (ESRD) is permanent kidney failure, Stage V chronic kidney disease, requiring a regular course of dialysis or kidney transplant.
ESRD Medicare Eligibility
An individual of any age is entitled to premium-free Medicare Part A if they have ESRD and they either worked the required amount of time under Social Security, the Railroad Retirement Board (RRB) or as a government employee, are already receiving or are eligible for Social Security or RRB benefits, or are the spouse or dependent child of a person who meets either of those requirements.
If an individual qualifies for Medicare Part A, they can also get Medicare Part B. An individual will need both Part A and Part B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services.
When an individual's Medicare coverage begins depends on their treatment plan. See the chart below:
If a person has Medicare only because of permanent kidney failure, Medicare coverage will end:
- 12 months after the month they stop dialysis treatments.
- 36 months after the month they have a kidney transplant.
Their Medicare coverage will resume if:
- They start dialysis again, or get a kidney transplant within 12 months after the month they stopped getting dialysis.
- They start dialysis or get another kidney transplant within 36 months after the month they get a kidney transplant.
Note: Medicare offers a benefit that helps pay for immunosuppressive drugs only beyond 36 months if a person had Medicare because of ESRD at the time of kidney transplant and do not have nor expect to get other health coverage (such as a group or individual health plan or Tricare). A monthly premium and annual deductible may apply.
ESRD Medicare Enrollment
If an individual has End Stage Renal Disease (ESRD), enrolling in Medicare is an option. If entitled to Medicare because of ESRD, an invididual can enroll in Part A and Part B.
If an individual enrolls in Medicare Part A and waits to enroll in Part B, they may have a gap in coverage. If an individual does not enroll in Part B at the time enrolls in Part A, they must wait until a Medicare General Enrollment Period (GEP) (January 1-March 31 each year) to apply. Coverage would begin the first of the month after they enroll and a Medicare Part B Late Enrollment Penalty may apply.
There is no Special Enrollment Period (SEP) for Part B if an individual has ESRD. This includes individuals who are dually entitled to Medicare based on ESRD and age or disability.
If an individual is already enrolled in Medicare based on ESRD and turns 65, their Medicare coverage will not be interrupted, as long as meets the eligibility requirements for Medicare based on age. If they did not have Part B before turning age 65, they will automatically be enrolled in Part B when they turn 65.
If an individual is already enrolled in Medicare A&B based on disability or age and paying a higher Part B premium because they did not enroll in Part B when first eligible, they will no longer have to pay the late enrollment penalty when becomes entitled to and enrolls in Medicare based on ESRD.
A person can enroll in ESRD Medicare by contacting their local Social Security Office. If help is needed to decide when to enroll, call the Medigap Helpline (1-800-242-1060) for further assistance.
ESRD Medicare Enrollment Considerations
Medicare and Group Health Plan (GHP) Coverage
If an individual is entitled to Medicare based solely on ESRD, Medicare is the secondary payer to Group Health Plans (such as an employer or union) during a coordination of benefits period of up to 30 months. The GHP will pay first on hospital and medical bills during this period regardless of how many employees the employer has or whether a person is currently employed or retired. This is also true in dual entitlement situations wherein an individual, already entitled to Medicare on the basis of age or disability and Medicare was the secondary payer, has now become entitled to Medicare based on ESRD.
The 30-month coordination period begins when an individual becomes entitled to ESRD Medicare (even if not yet enrolled). When an individual is within this coordination period the GHP must pay primary benefits during this period even if their GHP says its policy is to pay second to Medicare. If the GHP does not pay for covered services in full, Medicare may pay secondary benefits for all Medicare covered items and services, not just those for the treatment of ESRD. At the end of the 30-month coordination period, Medicare then becomes the primary payer even if the person remains covered under the GHP based on current employment status.
If an individual has GHP coverage that will pay for most or all of their health care costs (for example, if there is no annual deductible) they may want to delay enrolling in Medicare Part A and Part B until they get near the end of the 30-month coordination period. If enrollment is delayed, they won’t have to pay the Part B premium for coverage not yet needed. After the 30-month coordination period, they may enroll in Part A and Part B.
ESRD Medicare and the Health Insurance Marketplace
If an individual is currently enrolled in a Health Insurance Marketplace plan and becomes entitled to ESRD Medicare, they have the choice to enroll in ESRD Medicare or stay enrolled in their Marketplace plan. Consider all consequences carefully before deciding to keep a Marketplace plan and delay enrolling in ESRD Medicare.
An individual may be eligible for premium-free Part A, but not required to sign up for Medicare. If they choose to enroll in premium-free Part A, the beneficiary should enroll in Medicare Part B at the same time to ensure they are getting full coverage for dialysis and kidney transplant services (and to avoid a potential gap in coverage and/or a Part B late enrollment penalty).
When Medicare Part A coverage starts, any premium tax credits and/or other cost-sharing savings received through the Marketplace will end and they will have to pay the full Marketplace premium. An individual can cancel the Marketplace plan once their Medicare coverage starts.
ESRD Medicare and Medicaid
If an individual is currently enrolled in a Medicaid program, careful consideration should be given as to when to enroll in ESRD Medicare. For example, if an individual is enrolled in Badgercare Plus, this coverage may end when Medicare begins. Badgercare Plus does not consider assets for eligibility so an individual may be eligible for this program but not other programs that do consider income and assets to determine eligibility.
If an individual enrolls in ESRD Medicare and is eligible for a Medicaid program, Medicare will pay primary (first) and Medicaid second.
Before deciding to delay enrollment, an individual should get all the facts about ESRD Medicare eligibility and enrollment for their situation, especially if a transplant is planned as there are shortened time periods for eligibility and enrollment for transplant recipients.
If an individual is entitled to Medicare Part A at the time of transplant and Medicare paid for their transplant (or was the secondary payer but made no payment) and the transplant took place in a Medicare-certified facility, then Medicare Part B will cover their immunosuppressive drugs (after enrolled in Medicare Part B). If these transplant conditions are not met, the immunosuppressive drugs may be covered by a Medicare Part D prescription drug plan.
Resources
