You can have as many kidney beans as you want. You only get two kidney though, and one in 1,000 people are born with only one. Unfortunately, those kidney(s) may not always work the way they are supposed to. When they fail, you may need dialysis or a kidney transplant. Not treating end-stage renal disease (ESRD) could be life threatening and that’s where Medicare can help.

Eligibility for ESRD Medicare

Medicare coverage for end-stage renal disease is different than other types of Medicare. Much of this is based on how you qualify for coverage.

First, you need to have end-stage renal disease that requires dialysis or a kidney transplant. That is self-explanatory.

Second, you, your spouse, or your parent/guardian (if you are a dependent) need to have paid into the system. That means paying enough in Medicare and Social Security taxes. You do so in one of the following ways:

• You already receive Social Security Disability or Railroad Retirement Board benefits -OR-
• You worked the required amount of time to qualify for Social Security benefits (see References below) or Railroad Retirement Board benefits -OR-
• You worked the required amount of time as a government employee.

When Coverage Starts

ESRD Medicare is unique in that your coverage starts based on what kind of care you receive.

• Dialysis at home: If you complete proper training to self-administer dialysis at home (*peritoneal dialysis) and that training is completed within the first three months of your treatment, Medicare will pay for care starting the first month you received dialysis. This means that payments can be retroactive.
• Dialysis in a clinic: If you go to a clinic, hospital, or medical office for your dialysis treatments (*hemodialysis), Medicare will start paying the fourth month of your dialysis treatments.
• Kidney transplant: Medicare benefits kick in the month you are admitted to a Medicare-certified hospital for a transplant as long as your transplant happens within two months. If your transplant is delayed by more than two months, your benefits will be delayed too. They will start two months before the transplant is actually completed.

In terms of the type of Medicare coverage you receive, you now have a choice between Original Medicare and a Medicare Advantage plan. People with ESRD Medicare could not sign up for a Medicare Advantage plan until 2021! You can thank the CURES Act for changing that.

*More people receive treatment with hemodialysis (84%) than peritoneal dialysis (16%).

Time Limits

Unlike other types of Medicare, your ESRD Medicare benefits could end based on how you respond to treatment.

• Dialysis: Regardless of the reason, coverage ends 12 months after stopping dialysis.
• Kidney transplant: Coverage ends 36 months after a successful kidney transplant.

If you need ESRD Medicare again in the future, there will be no waiting period for benefits. They will start back up as if you never stopped using it.

People who have a kidney transplant need to stay on life-long immunosuppressive medications to prevent their bodies from rejecting the organ. Losing Medicare after three years could leave them without coverage for these life-saving medications. For this reason, the government passed the BENES Act in 2020. It allows people with kidney transplants to receive a partial Part B benefit if they do not have other health coverage. The benefit would only cover their immunosuppressive medications and not other Part B services. The partial benefit will be a new offering starting in January 2023.

An Extra Bonus

Anyone paying Medicare late penalties before they went on ESRD Medicare can stop. The penalties will be forgiven and you get a clean slate.

 

Benefits Planner | Social Security Credits and Benefit Eligibility. (2022). SSA.gov. https://www.ssa.gov/benefits/retirement/planner/credits.html

End-Stage Renal Disease (ESRD) | CMS. (2021). CMS.gov. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/End-Stage-Renal-Disease-ESRD/ESRD

House Passes H.R. 2477, The “BENES Act of 2020.” (2020). SSA.gov. https://www.ssa.gov/legislation/legis_bulletin_121420.html

Mulcahy, J. (2020). MEDICARE ENROLLMENT & APPEALS GROUP FROM. https://www.cms.gov/files/document/allow-end-stage-renal-disease-esrd-beneficiaries-enroll-medicare-advantage-and-medicare-advantage.pdf

Sloan, C. E., Coffman, C. J., Sanders, L. L., Maciejewski, M. L., Lee, S.-Y. D., Hirth, R. A., & Wang, V. (2019). Trends in Peritoneal Dialysis Use in the United States after Medicare Payment Reform. Clinical Journal of the American Society of Nephrology, 14(12), 1763–1772. https://doi.org/10.2215/cjn.05910519