ESRD and Medicare Coverage

If you have ESRD, you are eligible for Medicare no matter what age you are, as long as your kidneys no longer work and you get regular kidney dialysis or had a kidney transplant, and as long as you meet certain work requirements.

Below we’ll examine what sort of Medicare benefits are available to people with ESRD, and we’ll explain the associated Medicare costs and eligibility rules.

Do I Have to Sign Up for Government Benefits for Dialysis?

No, you do not have to sign up for Medicare for ESRD.

While you don’t have to sign up for Medicare if you have ESRD, most people typically do, as Medicare Part A and Part B cover certain dialysis services and kidney transplants, as well as an extensive list of other benefits.

Most people know Medicare as being available to people age 65 and older, which is true. However, certain people can qualify for Medicare before the age of 65 if they have a qualifying disability. And one of those qualifying disabilities is ESRD, or kidney failure. 

If you have ESRD, you are eligible for Medicare at any age if your kidneys no longer work, you require regular dialysis or have had a kidney transplant and at least one of the following applies to you:

1. You have worked the required amount of time under Social Security, the Railroad Retirement Board or as a government employee.
   
   
2. You are eligible for Social Security or Railroad Retirement Board benefits.
   
   
3. You are the spouse or dependent child of someone who meets one of the requirements above.

While some people who qualify for Medicare under the age of 65 must first collect disability benefits for 24 months before receiving Medicare benefits, people with ESRD have no waiting period and may begin receiving Medicare right away.

You must contact Social Security to sign up for Medicare. You can enroll in Medicare by visiting your local Social Security office or by contacting a Social Security representative. 

If you qualify for Medicare only because of permanent kidney failure, your coverage will end 12 months after stopping dialysis or 36 months after receiving a kidney transplant. 

If you start dialysis again or get a kidney transplant within 12 months after you stopped getting dialysis, your Medicare coverage will resume. Medicare benefits will also resume for you if you start dialysis or get another kidney transplant within 36 months of receiving a kidney transplant.

2024 Medicare Advantage Plans for ESRD

Prior to 2021, people under the age of 65 with ESRD were not eligible for most Medicare Advantage (Medicare Part C) plans. These beneficiaries were only eligible to join a type of Medicare Advantage plan called a Medicare Special Needs Plan (SNP). 

The Centers for Medicare & Medicaid Services (CMS) issued a ruling in 2020, however, that allows people with ESRD to join Medicare Advantage plans.

Medicare Advantage plans are sold by private insurance companies and include all of the same basic benefits as Original Medicare (Part A and Part B). Most Medicare Advantage plans also typically offer additional benefits that Original Medicare doesn’t cover, such as dental, vision, hearing and prescription drug coverage. 

If you have ESRD and want to enroll in a Medicare Advantage plan, you can do so during the fall Medicare Open Enrollment Period, which lasts from October 15 to December 7 each year.

Medicare Prescription Drug Coverage With ESRD

If you qualify for Medicare because of ESRD, you will also be eligible to join a Medicare Part D prescription drug plan beginning three months before your date of Medicare eligibility and continuing for another three months thereafter. 

Medicare Part B provides coverage for transplant drugs needed after a kidney transplant and most of the drugs required for dialysis. Part D plans, on the other hand, are sold by private insurance companies and provide coverage for most prescription medications you get at a retail pharmacy that are unrelated to ESRD.  

Medicare Supplement (Medigap) Coverage With ESRD

Medigap, or Medicare Supplement Insurance, helps cover some of the out-of-pocket costs associated with Original Medicare such as deductibles, copayments and coinsurance. Medigap plans are sold by private insurance companies, but the benefits they offer are somewhat regulated by the federal government.

Beneficiaries who qualify for Medicare because of ESRD are not guaranteed to be able to enroll in a Medigap plan.

There are 33 states in which insurance companies are required by law to make at least one Medigap plan available to people with ESRD. In all remaining states, selling Medigap insurance to those with ESRD is at the discretion of the insurer. 

How Much Does Medicare Cost With ESRD?

If you have ESRD, you will not pay a premium for Medicare Part A. 

If you admitted for an inpatient hospital stay, you must reach a Part A deductible of $1,632 per benefit period in 2024 before your Part A benefits kick in. You don’t pay Part A coinsurance for inpatient hospital stays that last fewer than 60 days, but the coinsurance costs can reach as high as $800 per day in 2024 for hospital stays that last longer than 90 days.

Medicare Part B is optional and comes with a standard Part B premium of $174.70 per month in 2024. You are also responsible for meeting an annual Part B deductible that is $240 for the year in 2024. Once you meet your deductible, you’re typically responsible for paying a 20% coinsurance or copay for your covered services for the rest of the year.

Your costs for private Medicare plans such as Medicare Advantage plans, Medicare Part D plans or Medigap plans can vary based on where you live, the type of plan you have and the insurance carrier who manages your plan.