I have End-Stage Renal Disease (ESRD)

You can get Medicare no matter how old you are if all of these apply:

• Your kidneys no longer work
• You need regular dialysis or have had a kidney transplant
• One of these applies to you:
  • You've worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), 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

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.

• If you’re eligible for Medicare because of ESRD, you can enroll in Part A and Part B by visiting your local Social Security office or by contacting Social Security.
• Learn more about signing up for Medicare because of ESRD.

Eligibility for Medicare coverage based on ESRD works differently than other types of Medicare eligibility. If you’re eligible for Medicare based on ESRD and don’t sign up right away, your coverage could start up to 12 months before the month you apply.

Example: If you become eligible for Medicare based on ESRD in February, but don’t sign up for Medicare until November, your Medicare coverage will start in February (this is called retroactive coverage). 

If you’re on dialysis: 

• Medicare coverage usually starts on the first day of the fourth month of your dialysis treatments. This 4 month waiting period will start even if you haven’t signed up for Medicare.
  • Example: if you start dialysis on July 1, your coverage will begin on October 1, even if you don’t sign up for Medicare until December 1.
• If you're covered by an employer group health plan, your Medicare coverage will still start the fourth month of dialysis treatments. Your group health plan may pay the first 3 months of dialysis. 
• Medicare coverage can begin the first month of a regular course of dialysis treatments if you meet both of these conditions: 
  • 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 treatments.

Important: Medicare won’t cover surgery or other services needed to prepare for dialysis (like surgery for a blood access (fistula)) before Medicare coverage begins. However, if you complete home dialysis training, your Medicare coverage will start the month you begin regular dialysis, and these services could be covered. 

If you’re already getting Medicare due to age or disability, Medicare will cover physician-ordered fistula placement or other preparatory services before dialysis begins.

If you’re getting a kidney transplant: 

• Medicare coverage can begin the month you’re admitted to a Medicare-certified hospital for a kidney transplant (or for health care services that you need before your transplant) if your transplant takes place in that same month or within the next 2 months. 
  • Example: Mr. Green will be admitted to the hospital on March 11 for his kidney transplant. His Medicare coverage will begin in March. If his transplant is delayed until April or May, his Medicare coverage will still begin in March. 
• If your transplant is delayed more than 2 months after you’re admitted to the hospital (for the transplant or for health care services you need before your transplant), Medicare coverage can begin 2 months before your transplant. 
  • Example: Mrs. Perkins was admitted to the hospital on May 25 for some tests she needed before her kidney transplant. She was supposed to get her transplant on June 15. However, her transplant was delayed until September 17. Therefore, Mrs. Perkins’ Medicare coverage will start in July — 2 months before the month of her transplant.

If you have Medicare only because of permanent kidney failure, Medicare coverage will end:

• 12 months after the month you stop dialysis treatments.
• 36 months after the month you have a kidney transplant.

Your Medicare coverage will resume if:

• You start dialysis again, or you get a kidney transplant within 12 months after the month you stopped getting dialysis.
• You start dialysis or get another kidney transplant within 36 months after the month you get a kidney transplant.

Starting January 2021, people with ESRD can choose either Original Medicare or a Medicare Advantage Plan when deciding how to get Medicare coverage. Learn more about how Medicare Advantage Plans work, and how to enroll in a Medicare Advantage Plan.

Medicare Advantage Plans are a type of Medicare health plan offered by a private company that contracts with Medicare to provide all your Part A and Part B benefits. Most Medicare Advantage Plans also offer drug coverage. If you join a Medicare Advantage Plan with drug coverage, you'll get your drug coverage through your plan, and you can't enroll in a separate drug plan. Some Medicare Advantage Plans also offer extra coverage, like vision, hearing and dental coverage. Learn more about what Medicare Advantage Plans cover. Contact your plan for more information.

Important: In many cases, you’ll need to use health care providers who participate in the plan’s network and service area. Before you enroll, you may want to check with your providers and the plan you’re considering to make sure 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.

Learn more about Medicare Advantage Plans & find more questions to ask when you’re considering a Medicare Advantage Plan.

• Once you become eligible for Medicare based on ESRD, your first chance to join a Medicare drug plan will be during the 7-month period that begins 3 months before the month you’re eligible for Medicare and ends 3 months after the first month you’re eligible for Medicare. 
• Your prescription drug coverage will start the same time your Medicare coverage begins, or the first month after you make your request, whichever is later.
• Medicare Part B covers transplant drugs after a covered transplant, and most of the drugs you get for dialysis. However, Part B doesn’t cover prescription drugs for other health conditions you may have, like high blood pressure. Medicare offers prescription drug coverage (Part D) to help you with the costs of your drugs not covered by Part B. 

Learn more about prescription drug coverage.  

• There are other kinds of health coverage that may help pay for services and treatment related to ESRD. They include: 
  • Employee or retiree coverage from an employer or union 
  • Medicare Supplement Insurance (Medigap) 
  • Medicaid 
  • Veterans’ Administration benefits 
     

• How other coverage works with Medicare
  • If you’re eligible for Medicare only because of permanent kidney failure, your coverage usually can’t start until the fourth month of dialysis (also known as a “waiting period”). This means if you have coverage under an employer or union group health plan, that plan will be the only payer for the first 3 months of dialysis (unless you have other coverage).
  • Once you become eligible for Medicare because of permanent kidney failure (usually the fourth month of dialysis), there will still be a period of time, called a “coordination period,” when your employer or union group health plan will continue to pay your health care bills.
  • If your plan doesn’t pay 100% of your health care bills, Medicare may pay some of the remaining costs. This is called “coordination of benefits,” under which your plan “pays first” and Medicare “pays second.” During this time, Medicare is called the secondary payer (The insurance policy, plan, or program that pays second on a claim for medical care). This coordination period lasts for 30 months.
     

• The 30-month coordination period
  • The 30-month coordination period starts the first month you would be eligible to get Medicare because of permanent kidney failure (usually the fourth month of dialysis), even if you haven’t signed up for Medicare yet.
  • Important: If you have employer or union group health plan coverage, tell your health care provider that you have this coverage. This is very important to make sure that your services are billed correctly. At the end of the 30-month coordination period, Medicare will pay first for all Medicare-covered services. Your employer or union group health plan coverage may still pay for services not covered by Medicare. Check with your plan’s benefits administrator.
  • There’s a separate 30-month coordination period each time you enroll in Medicare based on permanent kidney failure. For example, if you get a kidney transplant that continues to work for 36 months, your Medicare coverage will end (unless you have Medicare based on your age or disability).
  • If after 36 months you enroll in Medicare again because you start dialysis or get another transplant, your Medicare coverage will start right away. There will be no 3-month waiting period before Medicare begins to pay. However, there will be a new 30-month coordination period if you have employer or union group health plan coverage.
     
• Do I have to get Medicare if I already have an employer or union group health plan?
  • No, but think carefully about this decision. If you get a kidney transplant, you’ll need to take immunosuppressive drugs for the rest of your life, so it’s important to know if they’ll be covered. Medicare only covers immunosuppressive drugs in specific circumstances.
  • If your group health plan coverage has a yearly deductible, copayment, or coinsurance, enrolling in Medicare Part A and Part B could help pay those costs during the coordination period. If your group health plan coverage will pay for most or all of your health care costs (for example, if it doesn’t have a yearly deductible), you may want to delay enrolling in Part A and Part B until the 30-month coordination period is over.
  • If you delay enrollment, you won’t have to pay the Part B premium for coverage you don’t need yet. After the 30-month coordination period, you should enroll in Part A and Part B. Your Part B premium won’t be higher because you delayed your enrollment in this situation. If your group health plan benefits are decreased or end during this period, you should enroll in Part A and Part B as soon as possible.
  • For more information about how employer or union group health plan coverage works with Medicare: 
    • Get a copy of your plan’s benefits booklet. 
    • Call your benefits administrator, and ask how the plan pays when you have Medicare.
       
• How the Health Insurance Marketplace works with Medicare
  • You aren’t required to sign up for Medicare. If you don’t have either Medicare Part A or Part B, you can get a Marketplace plan. You may also be eligible for tax credits and reduced cost-sharing through the Marketplace.
  • You generally can’t drop Medicare coverage to choose a Marketplace plan. Once you apply for Medicare, your Medicare coverage will end one year after you stop getting regular dialysis or 36 months after a successful kidney transplant. However, you may withdraw your original Medicare application. You would have to repay all costs covered by Medicare, pay any outstanding balances, and refund any benefits you got from Social Security or the Railroad Retirement Board. Once you’ve made all of the repayments, the withdrawal will be processed as though you never had Medicare at all.
     

In most states there are agencies and state kidney programs that help with some of the health care costs that Medicare doesn’t pay. Call your State Health Insurance Assistance Program (SHIP) if you have questions about health coverage. 

• Medicare Part A costs 
• Medicare Part B costs 
  • Enrolling in Part B is your choice. But, you’ll need both Part A and Part B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services.
  • Note: If you’re already enrolled in Medicare based on age or disability, and you’re already paying a Part B late enrollment penalty because you didn’t enroll in Part B when you were first eligible, the penalty will stop when you become eligible for Medicare based on ESRD. Call your local Social Security office to make an appointment to re-enroll in Medicare based on ESRD. 
  • For more information about the Part B premium visit socialsecurity.gov, Or, call 1-800-772-1213 (TTY: 1-800-325-0778).
•  Your costs in a Medicare Advantage Plan

End-Stage Renal Disease (ESRD) Networks and State Survey Agencies work together to help you with complaints (grievances) about your dialysis or kidney transplant care.

ESRD Networks

• ESRD Networks monitor and improve the quality of care given to people with ESRD and can help you with complaints about your dialysis facility or transplant center. If you have a complaint about your care:
  • You can complain directly to your facility, or you can file it directly with your Network. 
  • Your facility or Network must investigate it, work on your behalf to try to solve it, and help you understand your rights.
  • Your Network can still investigate a complaint and represent you, even if you want to remain anonymous.
  • Your facility can’t take any action against you for filing a complaint.
• Contact your ESRD Network for complaints like:
  • The facility staff doesn’t treat you with respect. 
  • The staff don’t let you eat during dialysis, and you’re always hungry. 
  • Your dialysis shifts conflict with your work hours, and the facility won’t let you change your shift.
  • You've made complaints to your facility, and they weren't resolved.

State Survey Agencies

State Survey Agencies also deal with complaints about dialysis and transplant centers (as well as hospitals and other health care settings). Your State Survey Agency can help you with complaints like:

• Claims of abuse
• Mistakes in giving out or prescribing drugs
• Poor quality of care
• Unsafe conditions (like water damage or electrical and fire safety concerns)

• If you have Original Medicare, your ESRD Network can help you:
  • Get your dialysis treatments
  • Find out who to contact for your supplies, drugs, transportation to dialysis services, and emergency financial help if you need it
• Call your ESRD Network for more information. You can also call us at 1-800-MEDICARE (1-800-633-4227) to get:
  • Your ESRD Network's contact information
  • More information about getting dialysis in a disaster or emergency
• If you have a Medicare Advantage Plan or other Medicare health plan:
  • Contact your plan first to see if it temporarily changes its rules in a disaster or emergency. Your ESRD Network can help you find facilities that give dialysis services in the area where you're staying temporarily. But, your plan may not have a contract with those facilities. Generally, you can find your plan's contact information on your plan membership card. Or, you can search for your plan's contact information. You can also call us at 1-800-MEDICARE.
• Learn more about getting care & drugs in disasters or emergencies.
   

You can still travel within the United States if you need dialysis. Your facility can help you plan your treatment along the route of your trip before you travel. Find out about Medicare’s coverage when you travel outside the U.S.

While you're traveling you may need to pay your co-pay when you get your dialysis. Check with the social worker at your dialysis facility to learn more.