Medicare Extends Special Services to People With Kidney Failure
Most costs from dialysis and transplants are covered, regardless of age
En español | In addition to the traditional coverage Medicare offers to the 65-plus population and Americans with disabilities, the program extends special services to people living with end-stage kidney disease, regardless of their age.
An estimated 30 million Americans have chronic kidney disease, a condition in which the kidneys are damaged and can't filter blood the way they should, according to the Centers for Disease Control and Prevention (CDC). When the disease progresses and the kidneys fail, either machine filtration (dialysis) or a kidney transplant is needed to survive.
Patients who are 65 or older and qualify for Medicare are automatically entitled to the kidney-care benefits. Younger patients must have enough work history credits, based on their age, to qualify for End-Stage Renal Disease (ESRD) Medicare. If they do not, some states offer assistance to help pay for dialysis treatments.
Qualifying for early Medicare
Two conditions allow people to receive Medicare quickly before age 65:
• Amyotrophic lateral sclerosis, also known as Lou Gehrig's disease
• End-stage renal disease, more commonly known as kidney failure
People younger than 65 who have been on Social Security Disability Insurance also can qualify but must wait 24 months before they can enroll in Medicare.
Patients with ALS can receive Medicare as soon as their disability benefits begin. Those with end-stage renal disease receive benefits within the first few months of kidney-failure care.
End-stage renal disease is one of two conditions that qualifies people for Medicare before the age of 65. Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease, is the other.
While people younger than 65 who have been on Social Security Disability Insurance have to wait for 24 months before they can enroll in Medicare, patients with ALS can receive Medicare as soon as those disability benefits begin.
For new enrollees, ESRD Medicare benefits begin in the first few months of kidney-failure care and are based on an individual's treatment plan. For example, coverage for at-home dialysis kicks in before dialysis at a hospital or an outpatient facility and typically ends 12 months after the beneficiary stops dialysis.
New enrollees receiving a kidney transplant collect Medicare benefits around the time they are hospitalized for surgery, and coverage, which includes immunosuppressant medications, ends 36 months after the transplant.
Because each person's situation is unique, Casey Schwarz, a senior counsel at the Medicare Rights Center, recommends that end-stage renal patients contact their local State Health Insurance Assistance Program (SHIP) or call the Medicare Rights Center National Helpline at 800-333-4114 to better understand individual coverage options.
Chronic kidney disease is most common in older adults, especially those who have diabetes and hypertension, but it can go undetected because of a lack of symptoms. In fact, 48 percent of people with severely reduced kidney function who are not on dialysis are not aware they have kidney disease, according to the CDC.
“As kidney disease gets worse and worse, the costs go up and up,” which is why Congress introduced ESRD Medicare almost 50 years ago when dialysis was available only to those who could afford it, says Holly Mattix-Kramer, a nephrologist and president of the National Kidney Foundation.
Today about 100,000 people begin dialysis each year — a treatment that costs about $90,000 per patient, per year, according to Mattix-Kramer.
More than 90 percent of Americans with kidney failure have Medicare. In 2016, treating beneficiaries with end-stage renal disease cost $35 billion.
Diagnosing kidney disease early is important to stop the advancement of kidney failure, Mattix-Kramer says, and also to reduce the risk for cardiovascular disease — the most common cause of death among people on dialysis.
"We need patients to be asking their providers, ‘Hey, doctor, how are my kidneys doing?’ “ she says. “If it's identified early, then we can educate patients on how to change their diet, how to be compliant with their medications and get their blood pressure controlled — or if they have diabetes, how to get their diabetes controlled — and how to avoid certain very common over-the-counter medications that can worsen kidney disease."
More than 661,000 Americans have kidney failure, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Kidney diseases are the ninth leading cause of death in the U.S.