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.
When ESRD Coverage Begins
When your coverage begins will depend on your treatment plan. Likewise, there are certain requirements you must meet to qualify for Medicare based on ESRD.
The four-month waiting period starts when you begin treatments, regardless of if you’ve applied for Medicare yet. So if you start dialysis on July 1 but don’t apply for Medicare until December 1, your coverage will be retroactively applied to begin on October 1. This also applies if you’re on an employer group health plan.
Your Medicare ESRD coverage can begin as early as the first month of your dialysis treatments if you meet certain conditions:
- First, you must participate in home dialysis training from a Medicare-certified training facility in the first three months of your dialysis treatments.
- Second, your doctor must state that he or she expects you to finish training and be able to perform your dialysis treatments.
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 be resumed if you restart dialysis or get a kidney transplant within 12 months of your last dialysis treatment. It can also resume 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?
You can enroll in Medicare for ESRD through your local Social Security office or by contacting the Social Security Administration at SSA.gov. Your healthcare provider or dialysis center will need to send documentation to SSA verifying you have ESRD and detailing the treatment you require. If you’re too ill to enroll yourself, another designated party such as a family member can enroll you on your behalf.
With ESRD, you can enroll in Medicare Part A and Part B. 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 for Part B. Even if you don’t elect to get Part B when you first enroll, you won’t incur a late enrollment penalty if you qualify for Medicare based on ESRD. Any late enrollment penalties you’re already paying will be removed once you qualify for ESRD Medicare.
You can also elect to get Medicare Part D for prescription drug coverage. Or, as of January 2021, people with ESRD can choose either Original Medicare, which is Medicare Parts A and B, or a Medicare Advantage Plan. Medicare Advantage Plans are offered by private insurance companies that contract with Medicare to provide the same coverage and benefits as Part A and Part B. These plans often include drug coverage and may provide additional benefits not offered by Original Medicare, like vision, dental and hearing coverage.
“If you get an Advantage Plan, please be aware of its network,” Hill says. “Consult your medical providers to see if they are in-network, otherwise, costs could be higher. This also applies to your drug coverage.”
John Hill, founder of Gateway Retirement in Rock Hill, South Carolina
Learn More From Our Sources
- CMS | End-Stage Renal Disease | Last accessed July 2021
- Medicare | I have End-Stage Renal Disease (ESRD) | Last accessed July 2021
- MedicareInteractive.org | ESRD Medicare basics | Last accessed July 2021
- MedicareInteractive.org | ESRD Medicare costs and coverage | Last accessed July 2021
- Medicare | How do I get Parts A & B? | Last accessed July 2021
- Medicare | Medicare Advantage Plans cover all Medicare Services | Last accessed July 2021