Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
End-Stage Renal Disease (ESRD) occurs when your kidneys stop working, and you require regular, long-term dialysis or a kidney transplant. Medicare provides coverage for people with ESRD regardless of age. ESRD Medicare eligibility requirements work differently than other types of Medicare eligibility. If you qualify for Medicare based on ESRD but don’t apply right away, you can get retroactive coverage to help pay for costs of services needed to treat your condition. ESRD Medicare works with other types of health coverage as well. Find helpful information about ESRD eligibility and coverage on Medicare.gov.
When ESRD Coverage Begins
Your coverage start date depends on your treatment plan (dialysis or kidney transplant).
If you are on dialysis, there is a four-month waiting period that starts when you begin treatments. Your Medicare ESRD coverage will start on the first day of the fourth month of your dialysis treatments. If you have not yet applied for Medicare, coverage can be retroactive.
Your coverage can begin as early as the first month of your dialysis treatments if:
- You participate in in-home dialysis training from a Medicare-certified training facility during the first three months of your dialysis treatments, and
- Your doctor expects you to finish training and be able to perform your dialysis treatments at home.
If you’re getting a kidney transplant, Medicare ESRD coverage can begin as early as the month you’re admitted to a hospital, provided your transplant takes place within the next two months. If your treatment is delayed for more than two months, Medicare coverage will begin two months before the date of your transplant.
ESRD Medicare coverage ends:
- 12 months after your last month of dialysis treatments, or
- 36 months after the month of your kidney transplant
Coverage can resume if:
- You restart dialysis or get a kidney transplant within 12 months of your last dialysis treatment, or
- If you start dialysis or get a kidney transplant within 36 months of your last kidney transplant.
How do you get Medicare Coverage for ESRD?
Eligibility requirements for ESRD Medicare include the following:
- Your kidneys no longer work
- You have had a kidney transplant or need regular dialysis
- You, your spouse or dependent child has worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee, OR you are already eligible for or getting Social Security or RRB benefits.
Contact Social Security for more information about the amount of time required to be eligible for Medicare. If you get benefits from the Railroad Retirement Board (RRB), call 1-877-772-5772.
You can enroll in Medicare for ESRD through your local Social Security office or contactthe Social Security Administration(SSA) at SSA.gov. Your healthcare provider or dialysis center must send documentation to SSA verifying your ESRD diagnosis and treatment plan. If you’re too ill to enroll yourself, a designated party such as a family member can complete the enrollment process for you.
With ESRD, you can enroll in Medicare Part A (hospital insurance) and Part B (medical insurance). You’ll need both Parts A and Part B to get full Medicare benefits for dialysis and kidney transplant service coverage. Most people qualify for premium-free Part A but you’ll need to pay monthly premiums ($170.10 in 2022) for Part B. If you qualify for Medicare based on ESRD and don’t elect to get Part B when you first enroll, you won’t incur a late enrollment penalty if you choose to get Part B later. If you are already paying Part B late enrollment penalties, they will be removed once you qualify for ESRD Medicare.
You can receive your Medicare benefits one of two different ways, through Original Medicare or through a Medicare Advantage Plan:
- Original Medicare Part A and B. You have the option to add:
- A Medicare Advantage Plan that includes Part A, B, and D benefits and coverage. Points to remember if you choose to join a Medicare Advantage Plan:
- Make sure that your providers and treatment facilities are in your plan’s network.
- You must be enrolled in Medicare Parts A and B to join a Medicare Advantage Plan.
- You cannot have a Medigap plan and a Medicare Advantage Plan at the same time.
- If you join a Medicare Advantage PPO or HMO, you cannot join a standalone Part D Prescription Drug Plan.
Learn More From Our Sources
- CMS | End-Stage Renal Disease | Last accessed November 2022
- Medicare | I have End-Stage Renal Disease (ESRD) | Last accessed November 2022
- Medicare | How do I get Parts A & B? | Last accessed November 2022
- Medicare | Medicare Advantage Plans cover all Medicare Services | Last accessed November 2022
- Medicare | Part D Prescription Drug Coverage | Last accessed November 2022
- Medicare | What is Medicare Supplement Insurance (Medigap?) | Last accessed November 2022
- SSA | Social Security: Contact Information | Last accessed November 2022