Can I get Medicare with ESRD (end-stage renal disease)?

If you're starting a regular course of dialysis, here's the timing: Medicare entitlement begins the first day of the third month after the month dialysis starts. So if dialysis starts in January, Medicare begins April 1. You can apply up to 3 months before that point.

File the application now — don't wait. Your dialysis center social worker has the forms (CMS-43 for ESRD) and files these all the time. If you're a candidate for self-dialysis training, ask whether starting that program could move your entitlement up to month 1.

If you (or your spouse) have group health coverage through an employer when ESRD entitlement begins, federal law requires the employer plan to pay primary for the first 30 months. Medicare is secondary during that coordination period. After 30 months, Medicare becomes primary regardless of whether you're still employed.

This applies even if the employer is small — the size-of-employer rules that apply to age-based or disability-based Medicare don't apply for ESRD. Talk with HR and ask for a written summary of how the plan coordinates with Medicare.

Transplant timing changes the entitlement rules. Medicare entitlement begins the first day of the month the transplant is performed. If you're admitted as an inpatient to a Medicare-certified transplant center for procedures leading up to surgery, entitlement can begin the first day of that admission month — or up to 2 months earlier if the transplant is delayed beyond 2 months from admission.

Medicare entitlement based on ESRD generally ends 36 months after a successful transplant. As of January 2023, an extended Part B benefit lets eligible kidney transplant recipients keep coverage for immunosuppressive drugs after that 36-month cliff. Talk with your transplant team's social worker.

Since 2021, ESRD patients have been able to enroll in Medicare Advantage (MA) plans. Before the 21st Century Cures Act took effect, ESRD patients were generally excluded from MA enrollment except in certain ESRD-specific Special Needs Plans. Plan availability and benefits vary by plan and service area.

Whether Original Medicare or an MA plan is right for you depends on your treatment team, network, prescription drug needs, and out-of-pocket budget. SHIP at one-eight-seven-seven-eight-three-nine-two-six-seven-five offers free, unbiased counseling. Chapter's licensed Medicare advisors can also walk through what's available where you live for free.

ESRD Medicare doesn't require you to have your own work record. You can qualify on a spouse's or parent's earnings if you meet the relationship and dependency rules under Social Security law. Children with ESRD can qualify on a parent's record. Spouses and divorced spouses can qualify on a current or former spouse's record (the duration-of-marriage rule applies only to divorced spouses).

You must still file an application for Part A, meet the medical determination of ESRD, and satisfy the waiting period (or qualify for an exception).

If you participate in a self-dialysis training program offered by a participating Medicare facility before the 3-month waiting period ends, your Medicare entitlement begins the first month dialysis started — not month 4. Three things have to be true: the program is approved, your physician certifies it's reasonable to expect you'll complete training and self-dialyze regularly, and you keep up the dialysis course through what would otherwise be the waiting period.

Home dialysis itself is covered under Part B once entitlement begins, including training, equipment, supplies, and certain support services.

If you're helping someone navigate ESRD Medicare, the dialysis center social worker is your single best ally — they file Medicare ESRD applications all day. Bring the patient's Social Security number, work history, employer plan information, dialysis start date, and treating physician's name.

If the patient can't file the application themselves because of physical or mental condition, a relative or other responsible person can file on their behalf under 42 CFR 406.13(d)(3). If no responsible person is available, the hospital or dialysis facility itself may file. SHIP at one-eight-seven-seven-eight-three-nine-two-six-seven-five offers free help for caregivers too.

ESRD Medicare touches every kind of household and the rules don't fit on a single page. If your situation feels off-script — maybe you're dual-eligible for Medicaid, returning to dialysis after a transplant failed, or coordinating with VA benefits or COBRA — don't try to figure it out alone.

Three free options: (1) your dialysis center's social worker, who navigates this every day; (2) SHIP at one-eight-seven-seven-eight-three-nine-two-six-seven-five for unbiased Medicare counseling; (3) a Chapter licensed Medicare advisor for plan-specific guidance in your area. None of them charge you.