Skip to content

Can I get Medicare if I have advanced kidney disease?

En español 

Yes, you can receive kidney-care benefits if you’re 65 or older and you enroll in Medicare. You also may be eligible for Medicare coverage before age 65 based on your kidney condition if you, your spouse or your parent (for dependent children) has earned enough work credits.

For Medicare purposes, permanent kidney failure is known as chronic kidney disease stage 5, or end-stage renal disease (ESRD). It means your kidneys have stopped working properly and you need regular dialysis or a kidney transplant to stay alive.

If you’ve been diagnosed with kidney failure, Medicare may waive its usual two-year waiting period required for people who qualify based on receiving Social Security Disability Insurance (SSDI). About eight in 10 Americans with kidney failure have Medicare coverage, according to the National Kidney Foundation.

End-stage renal disease is one of two conditions that allow people to receive Medicare quickly before age 65. The other is amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease.

To qualify, you need to earn 40 work credits toward Social Security by age 65, but younger people can qualify based on a sliding scale of work credits. Call Social Security at 800-772-1213 or sign up for a My Social Security account to find out how many work credits you have. Medicare’s Eligibility Tool can also offer guidance. 

Another option: You can qualify as the spouse or dependent child of a person who has earned enough work credits. Your State Health Insurance Assistance Program (SHIP) can help with Medicare enrollment and coverage questions.

Credits to qualify for Medicare

Workers who pay FICA taxes receive one benefit credit for every $1,510 in earnings in 2022 (the amount changes annually), earning a maximum of four credits a year. People diagnosed with kidney failure don’t always need 40 quarters to be eligible for Medicare benefits.

Younger than 24 Six credits in the three years before kidney failure
Ages 24 to 30 Half the work credits possible to be earned from age 21 until kidney failure
Ages 31 to 43 20 credits in the 10 years before kidney failure
Ages 44 to 61 20 credits in the 10 years before kidney failure plus two credits for every two years starting at age 44
62 and older  40 credits before kidney failure

When does coverage for kidney disease take effect?

If you’re 65 or older, you can receive kidney-related benefits from Medicare anytime after you enroll.

For new enrollees younger than 65, Medicare coverage begins based on the dialysis or kidney transplant you need: 

  • If you’re using a dialysis center, Medicare coverage can start the first day of the fourth month of dialysis treatment and continues for up to 12 months after you stop dialysis.

  • If you’re in a home dialysis program, your coverage can begin the first month of dialysis and continue for up to 12 months after you stop dialysis. 

  • If you’re getting a kidney transplant, you can generally receive Medicare benefits the month you’re admitted to the hospital. Coverage usually continues for 36 months after you’ve had the transplant and no longer need dialysis.

  • If you need to resume dialysis or have another transplant, coverage will begin again without a waiting period. If you’re also eligible for Medicare because of another disability or because you’re 65 or older, your coverage won’t end.

  • If you’re a transplant recipient and have met your 36-month coverage limit, starting in January 2023, Medicare Part B will continue to cover your transplant immunosuppressive drugs at 80 percent. This includes people who have no other insurance coverage that contains a benefit for anti-rejection drugs.

New rules for Medicare Advantage and kidney disease

People with end-stage renal disease now can receive coverage either through original Medicare or a private Medicare Advantage plan. Before the 21st Century Cures Act of 2016 opened the door to coverage beginning Jan. 1, 2021, people with kidney failure couldn’t enroll in Medicare Advantage. 

At age 65, you can sign up for Medicare Advantage when you first enroll in Medicare parts A and B. You can also sign up or switch plans during open enrollment from Oct. 15 to Dec. 7, with new coverage starting Jan. 1.

If you’re younger than 65, you can enroll in Medicare Advantage when you first become eligible for Medicare under ESRD rules after signing up for parts A and B. You can also sign up for Medicare Advantage or switch plans during open enrollment each year. 

Before choosing a Medicare Advantage plan, make sure your care team (including your primary care physicians, dialysis provider, nephrologist, transplant center and other specialists, such as cardiologists and endocrinologists) are part of the plan’s network. Review the coverage annually during open enrollment to verify that your providers are still in your network. If you’re pursuing a kidney transplant, find out how the plan will cover Part B medications, such as those to prevent rejection of the transplant.

Keep in mind

If you’re younger than 65 and qualify for Medicare because of ESRD, find out about your state’s rules on Medicare supplement policies, also called Medigap, before deciding between original Medicare and Medicare Advantage. These rules may be a deciding factor in your choice.

Even though you can buy a Medigap policy within six months of signing up for Medicare Part B at age 65, regardless of preexisting conditions, rules for younger people vary by state. These plans can help pay out-of-pocket costs for parts A and B of original Medicare.

Some states don’t have guaranteed issue rights for Medigap if a Medicare beneficiary is younger than 65, which makes it difficult to qualify for coverage with a preexisting condition such as ESRD. Contact the SHIP program in your area to learn more about your state’s rules. 

Updated May 16, 2022

     

     


Latest Health News

View More