Medicare With Kidney Failure (ESRD)

The fourth month of dialysis is already marked on a calendar you have not seen. Medicare drew it there the day your treatments became regular, whether you have signed anything or not. This page is that calendar: the day coverage can start, the days it can move, and the one date no other Medicare has, the day it can end.

Can I get Medicare with kidney failure (ESRD)?

Yes, at any age. End-Stage Renal Disease, ESRD, is permanent kidney failure that requires a regular course of dialysis or a kidney transplant. If your kidneys no longer work, you need regular dialysis or have had a transplant, and you meet a work or benefits test, Medicare is open to you.

Medicare states the conditions as one set, and all of them must apply:

• Your kidneys no longer work.
• You need regular dialysis or have had a kidney transplant.
• You pass a work or benefits test, described next.

The test has three doors, and any one of them is enough. You have worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee. You are already getting, or are eligible for, Social Security or Railroad Retirement benefits. Or you are the spouse or dependent child of a person who meets either of those.

One more sentence of Medicare's deserves its place this early. Signing up for Medicare because of ESRD is your choice. But you will need both Part A and Part B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services.

Saying yes starts a clock, and the clock has more than one speed.

When does coverage start?

If you are on dialysis, Medicare coverage usually starts on the first day of the fourth month of your dialysis treatments, and the wait runs even if you have not signed up. Home dialysis training can move the start to month one. A transplant sets its own start dates.

Having an employer group health plan does not move the line. Medicare states that your coverage will still start the fourth month of dialysis treatments, and that your group health plan may pay the first 3 months of dialysis.

The month one exception has three conditions, and Medicare states all three:

• You participate in a home dialysis training program offered by a Medicare-certified training facility during the first 3 months of your regular course of dialysis.
• Your doctor expects you to finish training and be able to do your own dialysis at home.
• You maintain a regular course of dialysis throughout the waiting period that would otherwise apply.

Here are the four start rules in one place.

Your situation	When Medicare can start	The catch
A regular course of dialysis	The first day of the fourth month	The wait runs even if unenrolled
Home dialysis training, all conditions met	As early as the first month of dialysis	The training facility must be Medicare certified
Admitted for a kidney transplant	The month you are admitted	Transplant that month or within 2 months
Transplant delayed past those 2 months	2 months before the transplant	The start date moves with the surgery

Four rows, four published rules, and the first one runs whether you signed up or not.

What that coverage actually pays for, while you are on dialysis, is the next question.

What does it cover for dialysis?

Certain dialysis and kidney transplant services, with both parts working together. Medicare's own framing is that you will need both Part A and Part B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services. Part B also covers most of the drugs you get for dialysis.

The drug line has a boundary worth reading twice. Medicare Part B covers transplant drugs after a covered transplant, and most of the drugs you get for dialysis. It does not cover prescription drugs for other health conditions you may have, like high blood pressure. Medicare offers drug coverage, Part D, to help with the costs of drugs Part B does not cover.

Getting ready for dialysis has its own rule. Medicare will not cover surgery or other services needed to prepare for dialysis, like surgery for a blood access, called a fistula, before Medicare coverage begins.

That rule has two exceptions, and both are Medicare's. If you complete home dialysis training, your coverage starts the month you begin regular dialysis, and these services could be covered. And if you already have Medicare because of age or disability, Medicare will cover physician-ordered fistula placement or other preparatory services before dialysis begins.

Dialysis is one door in. The other is surgery, and its calendar runs differently.

What about a transplant?

A transplant sets both a start and, later, a possible end. Medicare coverage can begin the month you are admitted to a Medicare-certified hospital for the transplant, or for care you need before it, if the transplant happens that month or within the next 2 months.

Surgery dates move, and Medicare's rule moves with them. If your transplant is delayed more than 2 months after you are admitted, Medicare coverage can begin 2 months before your transplant. The start date follows the surgery, not the admission.

After a covered transplant, the drug rule from the last section carries forward: Part B covers transplant drugs, and they sit on the Part B side of the line rather than in a separate drug plan.

That is the start. The exit has its own rules, and they deserve a slow read.

Does coverage end after a transplant?

It can, and that makes this route unlike any other on the pages read for this cluster. If you have Medicare only because of permanent kidney failure, coverage ends 12 months after the month you stop dialysis treatments, and 36 months after the month you have a kidney transplant.

ESRD Medicare is the only Medicare with an exit built into it. That sentence is this publication's reading rather than Medicare's. Medicare states the two end rules above. On the pages read for this cluster, no other route into Medicare has an end rule stated anywhere. Naming kidney failure as the one route that can expire is ours.

The word only in Medicare's rule is load bearing. The end rules apply if kidney failure is your only reason for having Medicare. A reader who also qualifies by age or disability is not the reader these two dates are about.

The end rules apply if kidney failure is your only reason for having Medicare.

Say you have Medicare only because of kidney failure and you get a transplant in March. Thirty-six months after that month, your Medicare ends. Start dialysis again, or get another transplant, inside that window and your coverage resumes.

Medicare states the resume rules in full. Coverage resumes if you start dialysis again or get a kidney transplant within 12 months after the month you stopped dialysis. It also resumes if you start dialysis or get another transplant within 36 months after the month of a transplant.

And if the window has closed, the door is not locked. If you sign up for Medicare again because you start dialysis or get another transplant, your coverage starts right away, with no 3 month wait.

An ending that can restart is still an ending, which makes the sign up itself worth doing carefully.

How do I apply for Medicare with ESRD?

Through Social Security, and by choice rather than automatically. Medicare says to contact your local Social Security office, or call Social Security, to sign up for Part A and Part B because of ESRD. Waiting does not always cost the months in between, because coverage can reach back, within a published limit.

The numbers Medicare publishes: call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778. If you get Railroad Retirement Board benefits, call 1-877-772-5772.

The reach back is called retroactive coverage. Medicare states that if you are eligible based on ESRD and do not sign up right away, your coverage could start up to 12 months before the month you apply.

There is also a rule here that can end a penalty you are already paying. If you apply for Medicare and you are approved because of ESRD, you can sign up for Part B without paying a late enrollment penalty.

The same rule runs backwards for a penalty already in motion. If you already have Medicare because of age or disability and currently pay a Part B late enrollment penalty, you will need to sign up again for Medicare because of ESRD to stop paying it.

The shape of your coverage is also a choice at this step. People with ESRD can choose either Original Medicare or a Medicare Advantage Plan.

Medicare attaches one instruction to that choice. Before you join a plan, check with your providers and the plan that the providers you currently see, like your dialysis facility or kidney doctor, or want to see in the future, like a transplant specialist, are in the plan's network.

What this means for you

Medicare with kidney failure is open at any age, usually starts the fourth month of dialysis, and can start earlier with home dialysis training or a transplant. It can also end: 12 months after dialysis stops, or 36 months after a transplant. Signing up runs through Social Security, and it is your choice.

The clock in runs on its own. The fourth month arrives whether you signed up or not, and retroactive coverage can reach back up to 12 months from the month you apply.

The clock out is the rule to hold onto. On the pages read for this cluster, no other route into Medicare has one. Both end dates carry their own resume rules, and a restart after the window closes begins right away, without the 3 month wait.

For the disability benefits route and its 24 month clock, this cluster carries a disability page. For the ALS route, it carries an ALS page. For how Medicare and a job's insurance share bills in general, this publication's employer insurance page holds that ground.

FAQ

Do I have to sign up for Medicare if I have ESRD?

No. Medicare states that signing up for Medicare because of ESRD is your choice. It states the consequence in the same breath: you will need both Part A and Part B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services.

So the choice is real, and so is what each side of it produces. Declining is allowed, and the full dialysis and transplant benefit set is described as needing both parts. This page states both halves and stops there, because which way to go depends on coverage you may already have, and that is your situation rather than a rule.

Does my employer plan or Medicare pay first if I have ESRD?

For the first 3 months of dialysis, Medicare states that your employer or union group health plan is the only payer, unless you have other coverage, because ESRD Medicare usually cannot start until the fourth month.

After that a coordination period begins: your plan pays first and Medicare pays second. Medicare states that this coordination period lasts for 30 months, and that at the end of it Medicare pays first for all Medicare-covered services.

There is a separate 30 month coordination period each time you sign up for Medicare based on permanent kidney failure, so a restart after a transplant window brings a new one if you still have employer coverage.

When can I join a Medicare drug plan with ESRD?

Medicare publishes the window. Once you become eligible for Medicare based on ESRD, your first chance to join a Medicare drug plan is a 7 month period. It begins 3 months before the month you are eligible and ends 3 months after the first month you are eligible.

Your drug coverage starts when your Medicare coverage begins, or the first month after you make your request, whichever is later. The drug plan matters because of a boundary this page covers: Part B pays for most dialysis drugs and for transplant drugs after a covered transplant, and it does not pay for drugs treating your other conditions.

What happens to COBRA if I sign up for Medicare with ESRD?

Medicare states two rules about COBRA coverage through a job. If you are currently working and have COBRA when you sign up for Medicare, your COBRA will probably end.

If you become eligible for COBRA after you are already signed up for Medicare, you must be allowed to take it. Then comes the part specific to this page: Medicare states that COBRA is always secondary to Medicare, unless you have ESRD.

Every word of that sentence is Medicare's, including the exception. This page carries it without elaboration, because the pages read for it do not elaborate, and an unless clause about your money and your care is not a place for guesswork.

Is there help with kidney care costs Medicare does not pay?

Medicare's own page points in two directions. It states that in most states there are agencies and state kidney programs that help with some of the health care costs Medicare does not pay.

And it directs questions about health coverage to your State Health Insurance Assistance Program, SHIP, which is the free counseling service this publication covers on its own page.

Neither of those is a program this article can describe in detail, because the pages read for it do not, and which programs exist depends on your state. What is published is that the help exists and that SHIP is the door Medicare names for reaching it.

Does Medicare cover dialysis I got before signing up?

It can reach back, within published limits. Medicare states that if you are eligible based on ESRD and do not sign up right away, your coverage could start up to 12 months before the month you apply, which it calls retroactive coverage.

The fourth month waiting period runs even if you have not signed up, so the clock and the reach back work from the same calendar.

One rule stays firm at the front: Medicare will not cover services preparing you for dialysis, like fistula surgery, before your coverage begins, with the home training and age or disability exceptions this page describes. The calendar decides, and it was running before you signed anything.