FAQs on Medicare and ESRD

I have ESRD. Am I eligible for Medicare?

You can apply for Medicare no matter how old you have all of these:

·         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.

You may contact Social Security for more information. If you get benefits from the Railroad Retirement Board (RRB), call 1-877-772-5772.

I’m on kidney dialysis or  I am a kidney transplant patient. How do I sign up for Part A and Part B?

You can enroll in Medicare Part A and Part B if you are eligible because of End Stage Renal Disease. You may visit your local Social Security Office or you may also contact them.

If you qualify for Part A, you can also get Part B. However, enrolling in Medicare is still your choice. But, you’ll need both Parts A and B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services.

If I enroll in Medicare because of ESRD, when does my Medicare coverage start?

When you enroll in Medicare because you have an ESRD and you’re on dialysis, Medicare coverage usually starts on the first day of the fourth month of your dialysis treatments. This waiting period will start even if you haven’t signed up for Medicare.

 If you're covered by an employer group health plan, your Medicare coverage will still start the fourth month of dialysis treatments. The first 3 months of your dialysis may be paid your employer group health plan.

Medicare coverage can begin the first month of a regular course of dialysis treatments if these conditions are met:

·  You participate in a home dialysis training program offered by a Medicare-approved 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 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.

When will my Medicare coverage ends because I have ESRD?

For cases 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 be extended 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.

I’m over 65 (or disabled) and only have Part A. Now that I have ESRD, can I sign up for Part B?

Yes. You can enroll in Part B without paying a late enrollment penalty if you apply for Medicare and are approved based on End-Stage Renal Disease (ESRD). You may  contact Social Security to enroll or for more information regarding enrollment.

I’m over 65 (or disabled). I’m paying a late enrollment penalty because I didn’t enroll in Part B when I was first eligible. Now that I have ESRD, do I need to continue to pay the higher Part B premium?

No. When you apply for Medicare and enroll in Part B based on ESRD, your Part B late enrollment penalty will be removed. Call your local Social Security office to make an appointment to re-enroll in Medicare based on ESRD. 

I have ESRD, but I haven’t signed up for Medicare. Can I get a plan through the Health Insurance Marketplace?

Yes. People with ESRD aren’t required to sign up for Medicare. If you have ESRD and 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.

 I have Medicare coverage due to ESRD. Can I drop my Medicare coverage and choose a Marketplace plan?

Generally speaking, NO. 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.