Academic journal article Health Care Financing Review

End Stage Renal Disease

Academic journal article Health Care Financing Review

End Stage Renal Disease

Article excerpt

Introduction

End stage renal disease (ESRD) is that stage of kidney impairment which is irreversible, cannot be controlled by conservative management alone, and requires dialysis or kidney transplantation to maintain life. The 1972 Amendments to the Social Security Act (Public Law 92-603) extended Medicare coverage to persons with ESRD, and the Social Security Amendments of 1978 (Public Law 95-292) made changes in the rules governing entitlement to Medicare designed to encourage self-dialysis and transplantation, and to eliminate a number of inequities and difficulties that existed under previous law. Persons eligible for Medicare because of ESRD are entitled to all the benefits available under the Medicare program, not just those directly related to ESRD such as renal dialysis and transplantation.

To be eligible for Medicare ESRD benefits, an application for Medicare must be filed and a physician must certify that the individual requires chronic dialysis or a kidney transplant to maintain life. In addition to having chronic renal failure, the person must either be entitled to a monthly insurance benefit under title 11 of the Social Security Act (or an annuity under the Railroad Retirement Act); be fully or currently insured under Social Security (railroad work may count); or be the spouse or dependent child of a person who meets one of the previous requirements. There is no minimum age limitation. Provided all eligibility requirements are met, a person's Medicare entitlement as a result of ESRD begins with the earliest of the following four occurrences:

* The third month after the month in which a course of dialysis is initiated. For example, if a course was initiated any time during the month of January, the date of entitlement would be April 1.

* The month a course of maintenance dialysis begins if the individual participates in a self-dialysis training program in an approved facility and is expected to complete the training successfully and self-dialyze thereafter.

* The month of transplant.

* The month an individual is admitted to an approved hospital for procedures preliminary to a transplant, if the transplant takes place within the following 2 months. If the transplant is delayed more than 2 months, Medicare coverage will begin the second month prior to the month the actual transplant takes place, or if earlier, the first day of the third month after maintenance dialysis began.

Because persons entitled to Medicare because of ESRD require medical services to maintain life, most ESRD patients enrolled in Medicare submit bills to Medicare. As a result the terms "enrollee" and "beneficiary" are used interchangeably in this chapter.

A person's entitlement as a result of ESRD terminates with the earliest of the following events:

* The day of death.

* The last day of the 12th month after a person no longer requires maintenance dialysis treatments.

* The last day of the 36th month after the month in which an individual receives a kidney transplant. If within 36 months after transplantation a person requires another transplant or returns to dialysis, there is no interruption in entitlement.

A person whose ESRD entitlement terminates may continue their entitlement if he or she is disabled or is 65 years of age or over. A person whose ESRD entitlement was ended will be re-entitled effective the month his or her new course of dialysis begins with no second qualifying period.

Table 9.1 shows the number of Medicare enrollees with ESRD by their treatment group as of December 31 of each year.

[TABULAR DATA 9.1 OMITTED]

* On December 31, 1990, Medicare covered 164,642 ESRD patients: 128,546 (78.1 percent) on dialysis and 36,096 (21.9 percent) with a functioning graft.

* The number of Medicare ESRD enrollees increased at an average annual rate of change (AARC) of 11.6 percent from 1978 through 1990. …

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