Am I eligible for Medicare?

If you have 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

Why do some people get Medicare automatically?

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.

How do I get Medicare?

If you’re eligible for Medicare because of ESRD and you qualify for Part A, you can also get Part B. Signing up for Medicare 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. You can sign up for Part A and Part B by contacting your local Social Security office or by calling Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

If you apply for Medicare and are approved because of ESRD, you can sign up for Part B without paying a late enrollment penalty, even if a penalty would normally apply. Also, if you currently have Medicare based on age or disability and you pay a Part B late enrollment penalty, the penalty will stop when you become eligible for Medicare based on ESRD.
When will my coverage start?

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.

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.
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 as early as the first month of a regular course of dialysis treatments if you meet all 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 at home.
    • You maintain a regular course of dialysis throughout the waiting period that would otherwise apply.
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. 
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. 
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.
When will my Medicare coverage end?

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

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.
What will I pay?

Your Costs will depend on the type of coverage you have.

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. 

 If you already have Medicare based on age or disability, and you’re already paying a Part B late enrollment penalty because you didn’t sign up for 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. 
What are my coverage options?

People with ESRD can choose either Original Medicare or a Medicare Advantage Plan for their Medicare coverage. 

Original Medicare Medicare Advantage Plan
  • Original Medicare includes Part A and Part B.
  • You can join a separate Medicare drug plan to get Medicare drug coverage (Part D).
  • You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
  • A Medicare Advantage Plan is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D.
  • Some Medicare Advantage Plans also offer extra coverage, like vision, hearing and dental coverage.  
In many cases, you’ll need to use health care providers who participate in the plan’s network and service area. Before you join a plan, 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. Contact your plan for specific information.

 Compare Original Medicare and Medicare Advantage side-by-side.

How does coverage for prescription drugs work?

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.  

How does other coverage work with Medicare?

There are other kinds of health coverage that may help pay for services and treatment related to ESRD, like: 

If you’re eligible for Medicare only because of permanent kidney failure, your Medicare 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, 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.

 

Tell your health care provider if you have employer or union group health plan coverage so they bill your services 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 that Medicare doesn't cover. Check with your plan’s benefits administrator for more information.

Can there be more than 1 coordination period?

There’s a separate 30-month coordination period each time you sign up for 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 after 36 months (unless you have Medicare based on your age or disability). If (after 36 months) you sign up for Medicare again because you start dialysis or get another transplant, your Medicare coverage will start right away. You won't have to wait 3 months before Medicare begins to pay. However, you'll have a new 30-month coordination period if you have employer or union group health plan coverage.

What happens if I have COBRA or TRICARE coverage?

  • If you’re currently working and have COBRA coverage through your job when you sign up for Medicare, your COBRA will probably end. If you become eligible for COBRA coverage after you're already signed up for Medicare, you must be allowed to take the COBRA coverage. It will always be secondary to Medicare (unless you have ESRD).
  • If you have TRICARE and are an active duty service member with ESRD, you should sign up for Part A and Part B when you’re first eligible.

Do I have to get Medicare if I already have an employer or union group health plan?

No, but think carefully about this decision. Here are some things to consider:

  • Medicare only covers immunosuppressive drugs in specific circumstances. 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 you'll have coverage.
  • If your group health plan coverage has a yearly deductible, copayment, or coinsurance, signing up for Medicare 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 signing up for Medicare until the 30-month coordination period is over.
  • If you delay signing up, 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 sign up for Medicare. Your Part B premium won’t be higher because you delayed when you signed up in this situation. If your group health plan benefits are decreased or end during this period, you should sign up for Medicare 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 does the Health Insurance Marketplace® work with Medicare?

  • You aren’t required to sign up for Medicare. If you don’t have Medicare, you might be able get a Marketplace plan. You may be eligible for tax credits and lower cost-sharing through the Marketplace.
  • You generally can’t drop Medicare coverage to choose a Marketplace plan. You can choose to withdraw your original Medicare application, but if you do, you'll have to repay all costs that Medicare covered, pay any outstanding balances, and refund any benefits you got from Social Security or the Railroad Retirement Board. Once you’ve made all of these repayments, your withdrawal will be processed.
How do I file a complaint about my ESRD-related care?

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 State Survey Agencies
  • 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 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)
For questions about a specific service you got, look at your Medicare Summary Notice (MSN) or log into your secure Medicare account. You can file an appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare drug plan.
What happens if I need dialysis in an emergency?
  • 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 to see if it temporarily changes its rules during 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.
     
How does dialysis work if I'm traveling?

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.

What’s the Part B Immunosuppressive Drug benefit?

If you only have Medicare because of End-Stage Renal Disease (ESRD), your Medicare coverage, including immunosuppressive drug coverage, ends 36 months after a successful kidney transplant.

Beginning January 1, 2023, Medicare will offer a new benefit that helps continue to pay for your immunosuppressive drugs beyond 36 months, if you don’t have other health coverage. This new benefit only covers your immunosuppressive drugs and no other items or services. It isn’t a substitute for full health coverage.

You can sign up for this new benefit starting October 1, 2022. If you sign up by December 31, your coverage starts on January 1, 2023. To sign up, call Social Security at 1-877-465-0355. This is a special phone number just for this program. TTY users can call 1-800-325-0788.

What will I pay for this benefit?

You’ll pay a monthly premium and an annual deductible.

  • The monthly premium for this benefit is $97.10 in 2023. Who pays a higher premium because of income?
  • The annual deductible is $226 in 2023. Once you’ve met the deductible, you’ll pay 20% of the Medicare-approved amount for your immunosuppressive drugs. 

Can I get help with these costs?

You may be able to get help paying for this benefit from programs that are offered through your state. Contact your state to apply.