Medicare Coverage for End-Stage Renal Disease (ESRD)

Important information:

Anyone with end-stage renal disease (ESRD) that is on dialysis or has received a kidney transplant, may apply for Medicare.

Medicare is a federal insurance program. It differs from Medicaid, a state-managed insurance program. Medicaid rules and coverage vary by state.

Medicare has three main parts:

• Medicare Part A: Covers hospital stays and has no premium costs.

• Medicare Part B: Covers outpatient services, including dialysis, lab tests, and doctor’s appointments. Part B also includes some post-transplant medications. There is a standard monthly cost for Part B, which is $185 for 2025. The premium cost increases yearly and is billed every three months.

• Medicare Part D: Covers prescription medications. If you have Medicaid, you may automatically receive Part D coverage.

Medicare eligibility for children with ESRD depends on:

• The parents' work history

• An interview with the Social Security Administration (1-800-772-1213)

Consider your current insurance plan before applying for Medicare. 

• If you have multiple insurance plans, billing follows this order:

  • Primary insurance is billed first.

  • Secondary and tertiary (third) insurance plans are billed for any remaining costs.

  • If you’re unsure which plan is primary, ask your social worker for help.

1. Employer-based insurance

   • For the first 30 months of Medicare eligibility, your employer-based insurance remains the primary coverage (called the coordination period).

   • The start of the 30-month coordination period for Medicare coverage depends on the type of dialysis your child is receiving. For peritoneal dialysis (PD), this period begins immediately. For hemodialysis (HD), it starts on the first day of the fourth month after dialysis begins.

   • After the 30-month period, Medicare becomes your primary insurance, and employer-based insurance becomes secondary.

2. Medicaid insurance

   • If Medicaid is your only insurance, there is no coordination period. Medicare will become primary, and Medicaid will cover any remaining costs.

   • Your Medicaid plan may help cover the Medicare Part B premium based on your family's income. Contact your state Medicaid office or county assistance office to find out if you qualify for this assistance. You will be responsible for the premiums if you do not qualify for this assistance.

3. Medicaid and employer-based insurance

   • If you have both Medicaid and employer-based insurance, Medicaid may cover the Medicare Part B premium. This is not automatic and is based on the family’s income. You will be responsible for the premiums if you do not qualify for this assistance. If you have Medicaid, it will remain your third, or tertiary coverage for remaining costs.

Medicare coverage matters!

Even if you’re satisfied with your current coverage, it’s important to consider Medicare. All insurance companies have the right to treat Medicare as the primary payer if you are eligible for coverage. This means that employer-based insurance plans and Medicaid may deny payment for medical bills if you qualify for Medicare but decide not to enroll. To avoid potential billing complications and challenges, Medicare advises applying for coverage prior to or soon after transplant.

To find out if your insurance has this policy, contact the member services department and ask to speak with an ESRD representative. Ask them for a copy of their policy and whether they retain the right to pay secondary. Each year, you should request a copy of their ESRD policy, as they reserve the right to make changes.

If your insurance retains the right to pay secondary, you need to confirm your eligibility for Medicare with the Social Security Administration. Once eligible, Medicare will become your primary coverage after the 30-month coordination period, with your current insurance as secondary.

It's important to understand this policy, as it can significantly impact your healthcare costs and insurance coverage. For more detailed information, you can visit the official Medicare website or consult with your insurance provider.

Instructions to apply for Medicare:

Sign the Medical Evidence Report (Form 2728)

• This report confirms ESRD status and notifies the ESRD Network 4.

• Your medical team will complete the report and give you the original copy. Bring this copy to your Social Security interview.

• We will also send a copy to the Social Security Office and ESRD Network 4 Office.

When to apply

• Medicare recommends applying as soon as you’re eligible.

• Some families choose to apply during the open enrollment period closest to the end of the coordination period.

• Open enrollment typically runs from January 1 to March 31 each year, with coverage starting July 1. Keep this in mind if you’re considering waiting to apply for Medicare during open enrollment.

• If you’re considering waiting, contact the Medicare Coordination of Benefits and Recovery Call Center at 855-798-2627. Ask to be transferred to the ESRD Medicare Coordination of Benefits Department to learn when your coordination period ends and when the next open enrollment period is.

For more details, visit the Medicare.gov website and search for ESRD (Medicare for ESRD).

Contact your CHOP nephology social worker with questions or concerns about insurance for ESRD at 215-590-2449.

Reviewed December 2024 by Carly Athan, MSW, LSW