Does Medicare Cover ALS & ESRD Treatments?

In addition to serving individuals age 65 and older, Medicare covers those with disabilities, and those with two specific diseases: ALS (Amyotrophic Lateral Sclerosis) and End-Stage Renal Disease (ESRD). Here is what you need to know.

What is ALS?

Amyotrophic Lateral Sclerosis (ALS), commonly known as Lou Gehrig’s Disease, makes motor neurons atrophy, causing patients to lose control of movement, speech, and eventually, breathing. Because degeneration can happen very quickly, ALS treatment can drain a family’s finances in a matter of months. There is no cure for ALS yet. 

Quick ALS facts

  • Every 90 minutes, someone is diagnosed with the disease and someone passes away from it.
  • Most people who develop ALS are between the ages of 40 and 70, with an average age of 55 at the time of diagnosis. However, cases of the disease do occur in people in their twenties and thirties.
  • ALS is 20 percent more common in men than in women. However, with increasing age, the incidence of ALS is more equal between men and women.
  • About 90 percent of ALS cases occur without a family history, which is known as sporadic ALS. The remaining 10 percent of ALS cases are inherited through a mutated gene, which is known as familial ALS.

What is ESRD?

End-Stage Renal Disease (ESRD), commonly known as kidney failure, 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.

Click here to read more about what Medicare covers when you need a kidney transplant.

Quick ESRD facts

  • Beginning in 2021, all ESRD beneficiaries will have the option to enroll in Medicare Advantage, even after diagnosis. Medicare Advantage is well-suited to provide ESRD beneficiaries with coverage due to its annual out-of-pocket limit for consumers, supplemental benefits, and ability to coordinate care.
  • ESRD, also known as stage 5 of Chronic Kidney Disease, occurs when an individual’s kidneys permanently stop functioning. Unless they can receive a kidney transplant, people with ESRD undergo dialysis, typically several times a week. In 2019 alone, over 520,000 people were treated for ESRD through renal dialysis, with an additional 220,000 who received a kidney transplant.
  • Currently, most beneficiaries with ESRD receive coverage through Traditional Fee-For-Service (FFS) Medicare. Some can enroll in Medicare Advantage under limited circumstances and beneficiaries who develop ESRD while enrolled in a Medicare Advantage plan can retain their coverage.

Requirements

Those with ESRD and ALS do not have to have been collecting Social Security for at least 24 months to be eligible for Medicare, unlike other disabilities. The same Medicare benefits apply for individuals with ESRD and ALS as they do for all other beneficiaries.

With these benefits, if you have been diagnosed with ALS or ESRD you gain the safety and benefit of essential health care coverage through Medicare, assuming you or your spouse have a work history that makes you eligible for Medicare (or, if the patient is a child, Medicare eligibility is based on a parent’s work history). 

The requirements for Medicare eligibility for people with ALS and ESRD are the following:

ALS- Immediately upon collecting Social Security Disability benefits, which occurs five months after being classified as “disabled”.

ESRD- Generally 3 months after a course of regular dialysis begins (ie, on the first day of the four months of dialysis), but coverage can be available as early as the first month of dialysis for people who opt for at-home dialysis.

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