Medicare and End-Stage Renal Disease (ESRD)

End-Stage Renal Disease (ESRD) is a medical condition in which a person’s kidneys permanently cease functioning, leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life.  

Medicare covers ESRD….

if you are lucky enough to already have a plan. Even then, you may still be out of pocket for some of the expenses. Typically, that amount is not more than $4,000 to $6,000 per year. 


What if you are applying for coverage?

In Washington State, we are lucky to have guaranteed issue policies, but even on those, there’s one question that can deny you from some coverage…  

“Do you have End-Stage Renal Disease or ESRD?”

As long as I’ve been in the insurance industry, I’ve seen this question on Medicare applications. 

If you are applying for new Medicare Advantage Plans, you can be denied and here is how Medicare will process the cost:

  • Medicare pays most kidney doctors a monthly amount. 
  • After you pay the Part B yearly deductible (Part B covers dialysis overseen in a Medicare-approved outpatient dialysis facility), you will typically pay a 20% co-insurance for the cost of each session.

The cost for each session, and your co-insurance covers equipment, supplies, lab tests, and most dialysis medications. Doctors’ fees for certain services and items, such as intravenous iron therapy, are billed separately from the dialysis.

The big risk with only having Medicare coverage is that the outpatient procedures costs are not capped. As a result, you will pay the 20% co-insurance for each session. 


Note: ESRD Medicare does not cover surgery or services that are required to prepare you for dialysis before your Medicare eligibility begins. For example, Medicare will not pay for the surgery you need to create an access point for a dialysis machine.


Changes to Medicare regarding ESRD

At present, most cannot enroll in a Medicare Advantage Plan if they’re eligible for ESRD Medicare


Note: If you enrolled in a Medicare Advantage Plan prior to developing ESRD, you cannot be dis-enrolled. 


There are, however, exceptions we can discuss and options available to you.


The change

Starting this fall (2020), we will be able to accept Advantage Plan applications from Medicare eligible individuals with ESRD, and insurance companies are required to cover it as a Medicare expense.


Changing for the better

Things are changing within Medicare for the better. I will continue publishing and sharing articles here and on social media to help explain the changes, rules, and other pertinent information.

As always, if you have questions, my team and I are here to listen and help. 


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