End-Stage Renal Disease (ESRD)
End-Stage Renal Disease (ESRD) is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life. Beneficiaries may become entitled to Medicare based on ESRD. Benefits on the basis of ESRD are for all covered services, not only those related to the kidney failure condition.
Medicare is the secondary payer to group health plans (GHPs) for individuals entitled to Medicare based on ESRD for a coordination period of 30 months regardless of the number of employees and whether the coverage is based on current employment status. Medicare is secondary to GHP coverage provided through the Consolidated Omnibus Budget Reconciliation Act (COBRA), or a retirement plan. Medicare is secondary during the coordination period even if the employer policy or plan contains a provision stating that its benefits are secondary to Medicare.
The GHP may not differentiate in the benefits it provides to individuals who have ESRD. Specifically, GHPs are prohibited from terminating coverage, imposing benefit limitations, or charging higher premiums on the basis of the existence of the individual's ESRD.
When the beneficiary first enrolls in Medicare based on ESRD, Medicare coverage usually starts:
1. On the fourth month of dialysis when the beneficiary participates in dialysis treatment in a dialysis facility.
2. Medicare coverage can start as early as the first month of dialysis if:
- The beneficiary takes part in a home dialysis training program in a Medicare-approved training facility to learn how to do self-dialysis treatment at home;
- The beneficiary begins home dialysis training before the third month of dialysis; and
- The beneficiary expects to finish home dialysis training and give self-dialysis treatments.
Example: If the beneficiary starts home dialysis training in a Medicare approved facility, or if a course of home self-dialysis training is begun before the third month of dialysis, or if the beneficiary is expected to finish home dialysis training and perform self-dialysis on July 17th, the Medicare entitlement date would be July 1st.
3. Medicare coverage can start the month the beneficiary is admitted to a Medicare-approved hospital for kidney transplant or for health care services that are needed before the transplant if the transplant takes place in the same month or within the two following months.
Example: If the beneficiary has a kidney transplant on July 17th, the Medicare entitlement date would be July 1st.
4. Medicare coverage can start two months before the month of the transplant if the transplant is delayed more than two months after the beneficiary is admitted to the hospital for that transplant or for health care services that are needed before the transplant.
Example: If on July 17th the beneficiary starts pre-surgical health care services that are needed prior to a kidney transplant and the transplant is performed on September 4th, the Medicare eligibility date would be July 1st, since the transplant was performed within two months of the pre-surgical services.
5. Medicare coverage can start two months before the month of the transplant if the transplant is delayed more than two months after the beneficiary is admitted to the hospital for that transplant or for health care services that are needed before the transplant.
Example: The beneficiary was admitted to the hospital on May 25th for some tests that are needed before a kidney transplant. The transplant was to be on June 15th; however, the transplant was delayed until September 15th. Therefore, the beneficiary's Medicare coverage will start on July 1st, two months before the month of transplant.
When Medicare Coverage Ends
1. If the beneficiary has Medicare only because of ESRD, Medicare coverage will end when one of the following conditions is met:
- 12 months after the month the beneficiary stops dialysis treatments, or
- 36 months after the month the beneficiary had a kidney transplant.
There is a separate 30-month coordination period each time the beneficiary enrolls in Medicare based on kidney failure. For example, if the beneficiary gets a kidney transplant that continues to work for 36 months, Medicare coverage will end. If after 36 months the beneficiary enrolls in Medicare again because they start dialysis or get another transplant, the Medicare coverage will start right away. There will be no 3-month waiting period before Medicare begins to pay.