This article was updated on February 16, 2021.
Medicare is not just for seniors. This national health insurance program also covers people under 65 with certain disabilities, including kidney failure, also known as end-stage renal disease (ESRD).
What is kidney failure?
Kidney failure is the last of five stages of chronic kidney disease. At this point, the kidneys are only functioning between 10 to 15 percent, meaning they can no longer properly filter waste or fluid from the blood. This is a severe medical condition that usually requires life-long treatment.
If you’re younger than 65, you can medically qualify for Medicare coverage if:
- A doctor diagnoses you with kidney failure,
- You have had a kidney transplant, or
- You need regular dialysis.
To qualify for coverage, you must also:
- Have worked the appropriate amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee,
- Be eligible for or collecting benefits from Social Security or the RRB, or
- Be the spouse or dependent of someone who meets one of the previous requirements.
When does coverage for dialysis begin?
If you need dialysis, Medicare will usually begin the first day of the fourth month of dialysis. In other words, if you begin dialysis in June, Medicare coverage will begin on October 1. Note: this three-month waiting period may start before you have signed up for Medicare. If you begin dialysis in January but don’t apply for Medicare until March, your Medicare coverage may begin April 1.
Medicare coverage for dialysis can begin the first month of dialysis if you:
- Take training courses at a Medicare-approved facility to perform dialysis at home,
- Begin self-dialysis at home before the third month of treatment, or
- Expect to complete home dialysis training within the first month of self-dialysis training.
When does coverage for a kidney transplant begin?
Medicare coverage for a kidney transplant will begin the first of the month in which you receive the transplant. If you need pre-operative procedures before the transplant, your Medicare coverage will begin the month in which you receive these procedures as long as the transplant occurs within the next two months.
When does coverage expire?
If you are younger than 65 and only qualify for Medicare due to kidney failure treatment, the coverage will expire:
- 12 months after the last month of dialysis treatment, or
- 36 months after the month of a kidney transplant.
Medicare coverage may be resumed or extended if:
- You start dialysis again,
- You get a kidney transplant 12 months after your last month of dialysis, or
- You start dialysis or need another kidney transplant within 36 months of your previous transplant.
Does Medicare cover kidney transplant drugs?
Once you receive a new kidney via transplant, you will need to take immunosuppressive drugs for the rest of your life so that your body does not reject the new kidney.
These will be covered by Medicare Part B if you meet both of these conditions:
- You had Medicare Part A coverage at the time of the transplant, and
- Your transplant was performed at a Medicare-approved hospital.
If you are only eligible for Medicare coverage due to kidney failure treatment, your Medicare coverage of immunosuppressive drugs will end 36 months after the month of your transplant.
You may be able to extend the coverage of these drugs if:
- You were already eligible for Medicare before your kidney failure diagnosis, or
- You became eligible for Medicare (through age or disability) after receiving a Medicare-covered transplant.
Medicare Advantage coverage
Starting in January 2021, Medicare Advantage plans also cover people with ESRD. Medicare Advantage plans provide Medicare Part A and B coverage through a private insurer, and many plans also include Part D coverage. Some Medicare Advantage plans also cover vision, hearing, and dental.
Take note that with Medicare Advantage plans, you will need to use healthcare providers in your plan’s service area and network. Before choosing a plan, check to make sure your providers are in the plan’s network.
If you have been diagnosed with kidney failure and need to apply for Medicare coverage, you can do so at your local Social Security office. You can also call the Social Security Administration at 1 (800) 772-1213.