Medicare for People With End-Stage Renal Disease (ESRD)
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Most people become eligible for Medicare based on age, but turning 65 isn’t the only way to qualify. Millions of people below age 65 become eligible for Medicare based on disability.
End-stage renal disease (ESRD) is one condition that can make you eligible for Medicare based on disability. More than 500,000 Medicare beneficiaries have ESRD, and about 233,000 of them are under age 65.
Here’s what you need to know about Medicare eligibility and benefits for people with ESRD.
What is ESRD?
If you have end-stage renal disease, your kidneys no longer function well enough to meet your needs without dialysis or a kidney transplant, according to the Mayo Clinic. It’s sometimes also referred to as permanent kidney failure.
There are many disabilities that might qualify for Medicare under age 65, but ESRD is a special case with added rules and benefits.
Medicare eligibility based on ESRD
If you have ESRD, you can qualify for Medicare regardless of age if your kidneys no longer work, you need regular dialysis or have had a kidney transplant, and one of the following is true, according to the Centers for Medicare & Medicaid Services (CMS):
You've worked the required amount of time under Social Security, the Railroad Retirement Board or as a government employee.
You’re already getting or are eligible for Social Security or Railroad Retirement benefits.
You’re the spouse or dependent child of a person who meets either of the requirements listed above.
There are multiple ways to meet the Social Security work requirements depending on your work history and the onset of your ESRD. For help with the specifics, contact the Social Security Administration at 800-772-1213.
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What does Medicare cost with ESRD?
You’re still responsible for the costs of Medicare coverage, such as premiums and deductibles. Most people get Medicare Part A for free, but Medicare Part B has a monthly premium of $174.70 per month in 2024, for example.
If you choose a Medicare Advantage plan or stand-alone Medicare Part D prescription drug plan, you’ll also have premiums and certain deductibles, copays and/or coinsurance depending on the plan.
When does Medicare coverage for ESRD start?
Most people who qualify for Medicare based on disability have to wait 24 months for coverage to take effect. That’s not the case if you have ESRD.
In fact, your Medicare coverage can be retroactive to before you applied. If you become eligible for Medicare based on ESRD but don’t apply right away, your coverage can start up to 12 months before the month you apply.
Dialysis coverage
Medicare coverage for most people with ESRD starts on the first day of your fourth month of dialysis. If you train to do home dialysis, you might be able to qualify for coverage sooner.
Kidney transplant coverage
If you’re getting a kidney transplant, Medicare coverage starts the month you’re admitted to a hospital for the transplant or related pre-transplant services.
Your transplant must be scheduled for the month you’re admitted or the next two months. If the transplant is delayed or rescheduled more than two months out, your Medicare coverage can start two months before the transplant.
For example, if you’re admitted in January before a transplant scheduled in February, your coverage would start in January. But if the transplant is delayed until May, your coverage would start in March, instead.
When does Medicare coverage for ESRD end?
If you qualify for Medicare only because of ESRD, your coverage can end if you stop getting dialysis or after a transplant.
If you stop dialysis treatments, your coverage ends 12 months after the month you stop the treatments. You can resume your coverage if you start dialysis again or get a kidney transplant within that time period.
If you get a kidney transplant, your Medicare coverage ends 36 months after the month of the transplant. You can resume coverage if you start dialysis or get another kidney transplant within that time period.
If you qualify for Medicare for another reason, such as age or another disability, your coverage won’t end after dialysis or a transplant.
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