top of page
  • Writer's picture

End-Stage Renal Disease (ESRD) is a medical condition where a person has a permanent kidney failure. The kidney of anybody with this disease will no longer be able to function on their own. Because of this, they must get regular dialysis or have a kidney transplant to function. Medicare has been providing medical coverage for eligible people suffering from ESRD of all ages. However, this might mean a lot of out-of-pocket costs, and when they add up, the costs can become unbearable.

What Original Medicare Covers for People with ESRD

For people living with ESRD, original Medicare will cover most of their treatments and medication. By original Medicare, we mean Medicare Part A and Part B. Aside from the treatment and medication for ESRD, Medicare will also help cover some of the costs of any other ailment you have. Check out what Part A and Part B Medicare cover below.

Medicare Part A Covers the Following

· Dialysis treatments for when you are admitted to the hospital (inpatient dialysis)

· Registry fee for kidney

· The total cost of what is needed to take care of a kidney donor.

· All the medical care you need when admitted to the hospital. This includes drugs, food, and therapies.

· The entire cost of surgical procedures

· Limited care in a skilled nursing facility

· Hospice care

· Limited home healthcare

Medicare Part A Covers the Following

· Dialysis treatments in a Medicare-approved facility (Outpatient dialysis)

· Dialysis treatments at home

· Dialysis training, supplies, and equipment at home.

· Regular home check-ups by medical professionals and dialysis facility staff

· Doctor’s charges for the kidney transplant surgery

· Doctor’s charges for the kidney donor while the donor is still in the hospital

· Doctor’s or medical personnel appointment and service fee for outpatient services

· Injections and drugs for outpatients

· Medicare-approved medical equipment

· Emergency ambulance

· Most of the vaccines you need.

· Most of the screenings and diagnostic tests you need.

Medicare Advantage for ESRD

People with ESRD were not allowed new enrollment into a Medicare Advantage in the past. However, Congress has since changed this, and since the 15th of October 2020, people with ESRD have been able to enroll in a Medicare Advantage plan. You need to know that Medicare Advantage covers everything Original Medicare (Part A and Part B) does. So, how does this affect or benefit people with ESRD? You will get to learn this in a minute.

In addition, Medicare Advantage Plans may also cover some prescription medications that Medicare Part B will not cover under the Part D coverage offered on most plans. Furthermore, Medicare Advantage also has a cap of $7,550 on out-of-pocket costs to beneficiaries in 2021 for medical coverage. This means that regardless of how much out-of-pocket cost an ESRD patient accumulates, he/she won't pay more than the $7,550 cap. Keep in mind, the $7,550 is just the general out-of-pocket limit for Medicare Advantage Plans. There are some plans that can set their cap below this limit.

Again, we believe this further makes Medicare Advantage attractive for people with ESRD. The reason is that often, their out-of-pocket costs in a year tend to be higher than $7,550. Moreover, beneficiaries who elect to receive a Medicare Advantage do not have to purchase Medicare supplemental insurance which may have underwriting criteria that is hard to meet for patients with ESRD. Medicare Advantage Plans do not have health underwriting guidelines that would disqualify a beneficiary from coverage.

Furthermore, Medicare Advantage plans tend to ensure that patients with chronic illnesses or complex needs get the proper care. Considering this, ESRD patients can rest assured that enrolling in Medical Advantage can help them get the appropriate treatment or care they need. Finally, Medicare Advantage plans are usually tailored for the needs of every patient rather than the ‘generic’ and ‘usual’ service other programs have.

When Can People with ESRD Enroll in a Medicare Advantage Plan?

ESRD patients with Original Medicare that wanted to change to a Medicare Advantage plan can do so during the General Annual Election Period for Advantage and Prescription Drug plans which runs from the 15th of October till the 7th of December each year. Furthermore, from the 1st of January to the 31st of March every year, people with Medicare Advantage plans can also elect to choose a different Medicare Advantage plan. Beneficiaries with ESRD may qualify for a special election period during certain times throughout the year. If you are a ESRD patient, you should contact a Medicare insurance agent to see if you qualify.

My Final Word

If you have ESRD, you can either opt for Original Medicare or enroll for Medicare Advantage, depending on the one that suits you. You can check out the options you have here to make a better decision. Or you can use the Medicare Finder to do this. It would be best if you also found a Medicare insurance agent that will work to help you find a suitable plan. In general, we believe that having a choice to choose a Medicare Advantage plan is a welcome development for people living with End-Stage Renal Disease (ESRD).


bottom of page