Medicare for Kidney Failure (ESRD): Dialysis and Transplant at Any Age

Here's the short answer. If your kidneys have stopped working and you need regular dialysis or have had a kidney transplant, you can get Medicare at any age. Medicare calls this End-Stage Renal Disease, or ESRD. You also need a work record: you, your spouse, or a parent must have worked long enough under Social Security, the Railroad Retirement Board, or as a government employee, or you must be getting (or eligible for) Social Security or Railroad Retirement benefits. You don't have to wait 24 months the way people on disability benefits do. Coverage usually starts in your fourth month of dialysis, and it can start sooner if you train for home dialysis or get a transplant. If ESRD is your only reason for having Medicare, coverage ends 12 months after you stop dialysis or 36 months after a successful transplant.

Who qualifies for Medicare because of kidney failure

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

• Your kidneys no longer work.
• You need regular dialysis, or you have had a kidney transplant.
• One of these is true: you worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee; you already get or are eligible for Social Security or Railroad Retirement benefits; or you are the spouse or dependent child of someone who meets one of those tests.

Children with kidney failure can qualify through a parent's work record. Visit SSA.gov or call Social Security to confirm you meet the work test. Railroad retirees call the Railroad Retirement Board at 1-877-772-5772.

When ESRD Medicare coverage starts

ESRD works differently from every other kind of Medicare eligibility. The start date depends on your treatment, not on when you apply.

If you're on dialysis

• Usual start: the first day of the fourth month of your dialysis treatments. This 3-month waiting period starts even if you haven't signed up yet. If you start dialysis on July 1, coverage begins October 1, even if you don't sign up until December.
• Home dialysis training: coverage can start in the first month of dialysis if you join a home dialysis training program at a Medicare-certified facility during your first 3 months, your doctor expects you to finish training and do your own treatments at home, and you keep up a regular course of dialysis.
• Prep surgery: Medicare won't pay for surgery to prepare for dialysis (like creating a fistula for blood access) before your coverage starts. If you finish home dialysis training, coverage starts the month you began regular dialysis, so those services could be covered.
• Late sign-up: if you don't sign up right away, coverage can start up to 12 months before the month you apply. Become eligible in February but apply in November, and your coverage starts in February.

If you're getting a kidney transplant

Coverage can begin the month you're admitted to a Medicare-certified hospital for the transplant, or for care you need before it, as long as the transplant happens that month or within the next 2 months. If the transplant is delayed more than 2 months after admission, coverage can begin 2 months before the month of the transplant.

Signing up, and the Part B penalty

Signing up for Medicare because of ESRD is your choice. But you need both Part A and Part B to get the full benefits for dialysis and transplant care.

Two penalty rules work in your favor. If you're approved for Medicare because of ESRD, you can sign up for Part B without a late enrollment penalty. And if you already have Medicare because of age or disability and you're paying a Part B late penalty, you can sign up again based on ESRD to stop paying that penalty.

Your first chance to join a Part D drug plan is a 7-month window. It starts 3 months before the month you're eligible for Medicare and ends 3 months after the first month you're eligible. Part B covers transplant drugs and most dialysis drugs, but not drugs for other conditions like high blood pressure. Part D helps with those.

If you have a job-based or union plan: the 30-month rule

If you're eligible for Medicare only because of kidney failure and you have coverage through an employer or union group health plan, that plan is the only payer during the 3-month waiting period. Once Medicare starts, a 30-month coordination period begins. During those 30 months, your group plan pays first and Medicare pays second. If the plan doesn't cover 100% of a bill, Medicare may pick up some of the rest. When the 30 months end, Medicare pays first for all Medicare-covered services. Your group plan may still pay for things Medicare doesn't cover.

Tell your doctors and your dialysis facility that you have group coverage so they bill in the right order. There's a new 30-month period each time you sign up for Medicare based on kidney failure. For example, if a transplant keeps working for 36 months, your ESRD Medicare ends. If you later need dialysis again, Medicare starts right away with no 3-month wait, but a new 30-month coordination period begins.

Should you delay Medicare while the group plan pays first?

You don't have to take Medicare while you have a group plan, but think carefully. Medicare.gov points to these trade-offs:

• If your group plan has a deductible, copayments, or coinsurance, Medicare can help pay those costs during the coordination period.
• If the group plan pays most or all of your costs, you may want to wait until the 30 months are over. That saves you the Part B premium for coverage you don't need yet. Your Part B premium won't be higher later because you delayed in this situation.
• After a transplant you'll need immunosuppressive drugs for life. Medicare covers them only in specific situations, so know where that coverage will come from.
• If your group benefits shrink or end, sign up as soon as possible. After the 30-month period, you should sign up for Medicare.

COBRA works differently. If you have COBRA when you sign up for Medicare, it will probably end. If you become eligible for COBRA after you already have Medicare, you must be allowed to take it. Our Working Past 65 page explains how job coverage and Medicare fit together in general.

What Medicare covers for dialysis

With Original Medicare, Part A covers dialysis you get as a hospital inpatient. Part B covers the rest, including:

• Outpatient dialysis and doctors' services at a Medicare-certified facility or at home, including a monthly face-to-face visit with your doctor.
• Home dialysis training for you and your helper, plus home equipment and supplies like the machine, water treatment system, and a basic recliner.
• Drugs for outpatient and home dialysis, such as heparin, medicines for anemia caused by ESRD, and phosphate binders.
• Lab tests, nursing, social work, and dietitian services tied to dialysis. Ambulance rides to the nearest facility only when any other ride could endanger your health.

Medicare does not pay for a hired aide to help with home dialysis, lost wages during training, or a place to stay during treatment. For facility dialysis, you pay 20% of the Medicare-approved amount after the Part B deductible. Costs can differ in a Medicare Advantage plan or with a Medigap policy. See Understanding Your Costs for how deductibles and coinsurance work.

What Medicare covers for a kidney transplant

Part A covers the inpatient hospital care for the transplant, a kidney registry fee, tests for you and possible donors, the search for a kidney if you don't have a donor, and blood. Part A also covers the full cost of your donor's care, before, during, and after surgery. Neither you nor your donor pays a deductible or coinsurance for the donor's hospital stay.

Part B covers the doctors' services for the surgery and for your donor's hospital stay. If Medicare helped pay for your transplant, Part B also covers the immunosuppressive (anti-rejection) drugs. You pay 20% of the Medicare-approved amount for Part B services after the deductible, and nothing for Medicare-approved lab tests or for the donor's services. There's a limit on what a doctor can charge you even if they don't accept assignment.

Original Medicare, Medicare Advantage, and Medigap

People with ESRD can choose Original Medicare or a Medicare Advantage plan. Original Medicare lets you use any doctor or hospital that takes Medicare, anywhere in the U.S. Medicare Advantage plans usually require network providers. Before you join one, check that your dialysis facility, kidney doctor, and any transplant center you may need are in the plan's network. If you're on a transplant waiting list, also check the plan's prior authorization rules. Our edge cases page notes that ESRD patients have only been able to join Medicare Advantage since 2021.

Medigap is the catch. If you're under 65 and have Medicare because of ESRD or a disability, you might not be able to buy a Medigap policy until you turn 65. Federal law generally doesn't require insurers to sell Medigap to people under 65. Some states do require it, so check with your State Insurance Department. When you turn 65, you get a new Medigap open enrollment window.

When ESRD Medicare ends

If kidney failure is your only reason for having Medicare, coverage ends:

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

Coverage resumes if you start dialysis again or get a transplant within 12 months after stopping dialysis, or if you start dialysis or get another transplant within 36 months after a transplant. If you also qualify for Medicare because of age or disability, your Medicare doesn't end when the ESRD clock runs out. If your Medicare will end and you don't have other coverage, you may be able to use the Marketplace, with tax credits based on your income.

Help paying and getting problems solved

• State kidney programs. Most states have agencies and kidney programs that help with some costs Medicare doesn't pay. Your SHIP can point you to them.
• Medicaid and savings programs. If your income is limited, you may qualify for Medicaid alongside Medicare or a Medicare Savings Program. See Getting Help Paying.
• Complaints about dialysis or transplant care. ESRD Networks and State Survey Agencies handle complaints about dialysis facilities and transplant centers. You can complain to your facility or directly to your ESRD Network, and they must investigate.

Common questions

Official sources

• Medicare.gov: End-Stage Renal Disease (ESRD)
• Medicare.gov: Dialysis services & supplies
• Medicare.gov: Kidney transplants
• Medicare.gov: Medigap, get ready to buy (under 65 rules)
• Social Security (ssa.gov): sign up for Medicare based on ESRD