For Consumers

Medicare and people with End Stage Renal Disease (ESRD)

This information is for people who are eligible for Medicare solely because they have ESRD (permanent kidney failure) and are enrolled in other health coverage. It’s not intended for people who might be eligible for Medicare due to:

  • Another disability; or
  • Age

Medicare eligibility and applying

I have ESRD. Am I eligible for Medicare?

You can get Medicare, no matter how old you are, if your kidneys no longer work, you need regular dialysis or you had a kidney transplant, and one of these applies to you:

  • 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

If you’re enrolled in an individual health plan and qualify for Medicare due to ESRD, it’s not a requirement you sign up – it’s your choice. If you’re enrolled in coverage through your employer, your employer plan may require you to sign up for Medicare (see question and answer on “What does coordination of benefits mean?” for how Medicare due to ESRD works with employer insurance).

If I'm eligible due to ESRD, should I apply for Medicare?

Medicare enrollment can save you money on out-of-pocket costs, but it may not be right for everyone. We recommend you consult a social worker or the ESRD Network at 800-262-1514 to discuss how Medicare would work for you. 

Call your local Statewide Health Insurance Benefits Advisors (SHIBA) at 800-562-6900 and ask to speak with a SHIBA volunteer in your county for questions about:

  • Medigap policies
  • Medicare health plan choices
  • Filing an appeal
  • Other general health insurance questions

How do I apply for Medicare?

You must file an application and meet any deadlines or waiting periods that apply. Contact your local Social Security Administration (SSA) office (www.ssa.gov) to make an appointment to enroll in Medicare.

A dialysis facility or your doctor cannot complete the Medicare application on your behalf. However, doctors and other providers will need to send documentation to Social Security verifying you have ESRD and outlining what type of treatment you require.

Medicare services

What services does Medicare cover?

Medicare helps pay for kidney dialysis and kidney transplant services. Medicare has two parts:

1. Part A (Hospital insurance) helps pay for:

  • Inpatient hospital care
  • Some skilled nursing facility care
  • Hospice care
  • Some home health care

 

2. Part B (Medical insurance) helps pay for:

  • Doctors’ services
  • Outpatient hospital care
  • Some other medical services that Part A doesn’t cover, such as home health care


You’ll need both Parts A and B for Medicare to cover certain dialysis and kidney transplant services.

Medicare costs

How much does Medicare cost?

Medicare costs include premiums, deductibles and copayments/coinsurances (www.medicare.gov). Each year the costs may change.

You’re responsible for paying your monthly premium. If you stop paying your premium, your Medicare coverage will stop.

Can I get help with Medicare costs?

In some circumstances, if you have health insurance in addition to Medicare, your insurance carrier may offer to pay the costs of your Medicare premium. Generally, when companies pay a premium, they only pay the Part B premium costs. You’re still responsible for paying your other premiums.

If you’re on Medicare, you might also qualify for programs that could save you up to $150 per month:

What should I know about my costs?

Contact your insurance company to find out what your portion of costs might be for health services.

Sometimes there’s a difference between what your health insurance will pay and what a provider will bill. If the provider bills more than the insurance company pays, the provider, in some cases, will bill the extra amount to the patient. This is called “balance billing.” To reduce or eliminate balance billing, be sure to go to an in-network provider.

When to join or drop Medicare

When does Medicare coverage start?

When you first enroll in Medicare based on ESRD and you receive dialysis at an inpatient or outpatient dialysis facility, your Medicare coverage usually starts the fourth month of your dialysis treatments. For example, if you start getting your hemodialysis treatments in July, your Medicare coverage would start on Oct. 1.

In addition:

  • If you start a home dialysis-training program, then Medicare begins the first day of the month of the training program.
  • If you get a kidney transplant, Medicare starts the month you’re admitted to a Medicare-approved hospital for the transplant or for health services you need before getting the kidney transplant. You must receive the transplant either that same month or within the two months after your coverage starts. If the transplant is delayed, Medicare coverage starts two months before the month of transplant.

When does Medicare coverage end?

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

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

Your Medicare coverage will resume if:

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

Medicare and other health insurance

Do I have to give up my other health insurance coverage if I have Medicare?

Technically, no. However, be sure to read the rest of the information in this FAQ and talk with your non-Medicare health plan benefits administrator.

Can I apply for health insurance through the Washington Health Benefit Exchange (also called Washington Healthplanfinder)?

If you’re already enrolled in Medicare coverage, you cannot buy a qualified health plan sold through Washington Healthplanfinder (www.wahealthplanfinder.org).

If you’re enrolled in a qualified health plan you bought through Washington Healthplanfinder and then become eligible for and enroll in Medicare due to ESRD, you can keep your qualified health plan coverage. You must still meet the eligibility requirements for enrollment (i.e., criteria related to citizenship, lawful presence, incarceration and residency).

Important: When your Medicare Part A coverage starts you will lose your eligibility for premium tax credits and cost-sharing reductions for your qualified health plan.

What does "coordination of benefits" mean?

If you have Medicare and other health coverage, each type of coverage is called a “payer.” When there’s more than one payer, coordination of benefits rules decide which pays first. The primary payer pays what it owes on your bills first, and then your provider sends the rest to the secondary payer to pay. In some cases, there may also be a third payer. Please note that coordination of benefit timelines are different for people with ESRD.

For questions about which plan pays first, contact:

Medicare Benefits Coordination & Recovery Center
855-798-2627
TTY: 855-797-2627

What should I know about my doctor?

It’s important to find out if your provider is in- or out-of-network, or a participating provider with your health insurance company. Your costs for care depend on whether you’re using an in- or out-of-network provider. The best way to confirm if your provider is in-network is to contact your health insurance carrier.

Find out if your provider accepts Medicare by contacting your provider’s billing office directly.

To lower your out-of-pocket costs, it’s best to see a participating or in-network provider.

Contact information

Who do I contact for questions?

To discuss how Medicare due to ESRD might work for you, consult a social worker or the ESRD Network at 800-262-1514.

Call your local SHIBA at 800-562-6900 and ask to speak with a SHIBA volunteer in your county for questions about:

  • Medigap policies
  • Medicare health plan choices
  • Filing an appeal
  • Other general health insurance questions

 

Check out the Centers for Medicare & Medicaid Services publication “Medicare coverage of kidney dialysis & kidney transplant services” (PDF, 4MB) (www.medicare.gov).

To enroll in Medicare, contact the Social Security Administration (www.ssa.gov).

Disclaimer: This is general information about ESRD and Medicare. For personalized help, contact Medicare, Social Security, your insurer, and/or your local ESRD Network at 800-262-1514.