How Medicare Covers End-Stage Renal Disease (ESRD)
Key Takeaways
- Original Medicare (Parts A and B)Original Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). covers most of the treatment you’ll need with end-stage renal disease (ESRD), including medical services and supplies in hospitals, doctors’ offices, and at home.
- Individuals with ESRD are now eligible to enroll in Medicare Advantage (Part C)Medicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). . Medicare Advantage plans substitute for Original Medicare and set an annual out-of-pocket limit on covered services that can protect you from high costs.
- If you are eligible for Medicare because of ESRD but continue with your group health plan, Medicare can help as a secondary payer.
Medicare covers end-stage renal disease (ESRD) treatments, including dialysis and kidney transplant, for people of all ages. However, ESRD-based Medicare eligibility differs from age-based Medicare eligibility. Beneficiaries who qualify for Medicare because of ESRD must enroll right away to avoid delays in coverage, and they may lose their coverage after stopping dialysis or receiving a kidney transplant.
What Is ESRD?
ESRD, also called end-stage kidney disease (ESKD), occurs as a result of permanent kidney failure. Treatment involves a regular course of dialysis, which cleans a patient’s blood when their kidneys can’t, or a kidney transplant. As of 2023, more than 808,000 people in the U.S. had ESRD, of whom 68% were on dialysis, and 32% had a kidney transplant.
Without insurance, dialysis can be costly, averaging around $72,000 per year for patients undergoing three sessions per week. But if you’ve been diagnosed with ESRD, you qualify for Medicare — even if you aren’t yet 65 years old.
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How Medicare Covers End-Stage Renal Disease Treatment
Original Medicare (Parts A and B) covers treatment for ESRD, which may involve long-term dialysis or a kidney transplant. Everyone with ESRD qualifies for Medicare as long as they meet the following criteria:
- Their kidneys do not work.
- They have received a kidney transplant or they require regular dialysis.
- They have worked under Social Security, the Railroad Retirement Board (RRB), or as a government employee for the requisite amount of time; or they are receiving or eligible for Social Security or RRB; or they are a spouse or dependent of someone who meets one of the first two criteria.
People who qualify for Medicare based on ESRD alone may see some differences in their coverage compared to other Medicare beneficiaries.
Medicare coverage usually starts on the first day of the fourth month of your dialysis treatments. This four-month waiting period begins even if you haven’t yet signed up for Medicare. For example, if you start dialysis on July 13, your coverage will begin on October 1 even if you do not sign up for Medicare until December.
However, your Medicare coverage can begin as soon as the first month of your dialysis treatment if you participate in an eligible home dialysis training program. For eligibility, the program must be offered by a Medicare-certified training facility during the first three months of your dialysis treatment. The goal of the program is for you to finish training and be able to do your own dialysis treatments.
Part A: Hospital Coverage
Medicare Part A covers tests and services you receive during an inpatient hospital stay, including transplant services. It also helps pay for skilled nursing facility care, hospice, and some home healthcare services.
You can use Part A for:
- Blood transfusions
- Care before, during, and after a kidney transplant surgery
- Diagnostic tests
- Dialysis
- Finding the right kidney for a transplant
- Inpatient services in a Medicare-certified hospital
- Kidney transplant registry fee
- Lab tests and other tests to evaluate your and your donor’s medical condition
- Some costs of care for your donor
- Surgical procedures
Part B: Medical Coverage
Medicare Part B pays for outpatient services related to preventing, diagnosing, and treating medical conditions, including ESRD. It also covers ambulance services, emergency room visits, durable medical equipment, and vaccinations.
You can use Part B for:
- Blood transfusions (also covered under Part A)
- Dialysis training, supplies, and equipment for home
- Doctor’s services for kidney transplant surgery
- Doctor’s services for your kidney donor while they are in the hospital
- Home care from dialysis personnel and other medical providers
- Kidney function tests and other screenings and diagnostic tests
- Oral and injectable drugs for dialysis at home or in an outpatient setting
- Transplant drug therapy for a limited time following a transplant
Excluded From Coverage
Original Medicare does not pay for all prescription drugs, and it only covers immunosuppressive drugs for transplant recovery for a limited period after the surgery.
If you want more robust medication coverage, you’ll need Medicare Part D, also called the Medicare prescription drug benefit. You can purchase Part D as part of a Medicare Advantage plan or as a stand-alone plan through a private insurer.
Is Medicare Primary for ESRD?
If you are eligible for Medicare because of ESRD but continue with a group health plan, such as an employer-provided plan, Medicare becomes the secondary payer during your 30-month coordination period.
- Whether Medicare is your primary or secondary insurance for ESRD, Part B of Original Medicare — which provides medical insurance — will do much of the heavy lifting. For many services, Part B will pay 80% of eligible costs after you meet your annual deductible.
- Part A will cover hospital costs related to ESRD after you pay your benefit period deductible. Unlike Part B, Part A doesn’t have a monthly premium for most people, and the first 60 days in the hospital don’t require coinsurance.
- Medicare Advantage plans cover at least the same costs as Parts A and B.
How Medicare Advantage Covers ESRD
ESRD patients can choose between Original Medicare and Medicare Advantage, also called Medicare Part C. Medicare Advantage plans offer all the same coverage provided by Original Medicare, and may include additional benefits. You can purchase Medicare Advantage through a private insurance company.
Part C matches and some plans may exceed Original Medicare in its coverage of ESRD treatments. Part C benefits vary by plan, carrier, and region, so different plans may provide different levels of coverage. If you’re considering a particular Medicare Advantage plan, review its details to see how it covers ESRD treatment.
Consider a Chronic Condition Special Needs Plan
Chronic Condition Special Needs Plans (C-SNPs) serve beneficiaries with chronic conditions that require specialized care. C-SNPs are Medicare Advantage plans that provide personalized care for ongoing conditions such as diabetes, heart disease, and ESRD.
With a C-SNP, you’ll get an individualized care plan and a dedicated care team, plus specialized benefits for:
- Nephrologist care
- Prescription drugs
- Dental, vision, and hearing care
- Transportation to and from dialysis appointments
- Training, education, and supplies for dialysis and care management
- Over-the-counter health items
- Nutritional foods tailored to ESRD
How Medicare Works When You’re Under 65 With ESRD
If you are diagnosed with end-stage kidney disease and you’re under 65, you can apply for Medicare Part A. You can also enroll in Part B for more thorough coverage if approved. If you meet ESRD-based eligibility requirements but wait to apply for Medicare, you may receive retroactive coverage for up to 12 months before the month of your application.
Medicare Advantage and Medigap
As of 2021, all qualifying ESRD patients — regardless of age — are eligible for Medicare Advantage plans. However, enrolling in Medigap, or Medicare Supplement Insurance, may be trickier for patients under 65 years old.
Federal law does not require private insurers to offer Medigap policies to people under 65, even if they are diagnosed with ESRD. Many states require insurers to let people under 65 buy Medigap policies if they have ESRD, but 20 states do not. If you have ESRD and are under 65, your eligibility for Medigap depends on where you live. If you can buy a Medigap policy, it might cost more if you are younger.
ESRD Medicare Eligibility
No matter how old you are, you can get Medicare if your kidneys are no longer functioning and you either need regular dialysis or have undergone a kidney transplant. You must also meet one of the following criteria:
- You’ve worked for the required time period as a government employee or under Social Security or the RRB.
- You are receiving or eligible for Social Security or RRB benefits.
- You are married to or a dependent child of someone who meets either of the above criteria.
If you are eligible for Medicare, you must apply for Part A. Approval qualifies you to enroll in Part B as well.
For Patients on Dialysis
If you’re on dialysis, you’ll have a four-month waiting period before your Medicare coverage starts. This waiting period will start at the beginning of your dialysis treatment, regardless of when you sign up for Medicare. Some dialysis patients can receive benefits as early as the first month of treatment if they meet the following conditions:
- They complete a home dialysis training program through a Medicare-certified facility during their first three months of regular dialysis.
- Their doctor expects that they will finish training and transition to home dialysis.
- They maintain regular dialysis for the duration of the waiting period that would otherwise apply.
If you have secondary insurance such as an employer-sponsored health plan, your employer-provided insurance may cover your first three months of dialysis before the waiting period ends. Your Medicare coverage will end 12 months after the month in which you stop dialysis treatments. It may resume if you restart dialysis or get a kidney transplant within 12 months of stopping dialysis.
For Patients Receiving Kidney Transplants
If you’re receiving a kidney transplant, Medicare coverage can begin the same month you’re admitted to a Medicare-certified hospital for your transplant surgery as long as the surgery takes place that same month or in the following two months. If your surgery is delayed past that window, your coverage can begin up to two months before the transplant.
Your Medicare coverage will last for 36 months after the month in which you undergo a kidney transplant. If you start dialysis or receive another kidney transplant within 36 months after the month of your initial transplant surgery, your coverage may resume.
My Medicare coverage doesn’t address all of my needs.
How Much ESRD Treatment Costs With Medicare
Here’s how Original Medicare or Medicare Advantage might cover your ESRD treatment costs.
Inpatient Hospital Care
Part A covers 100% of your first 60 days in the hospital after you’ve met the Part A deductible ($1,676 in 2025). For days 61-90, you’ll pay $419 per day out-of-pocket (OOP). After day 90, you’ll pay $838 per day for each lifetime reserve day. After using all lifetime reserve days, you’ll pay the full cost OOP. Covered inpatient services include:
- Kidney transplants
- Kidney registry fees
- Inpatient dialysis treatments
As of 2020, the average kidney transplant cost $442,500 before insurance.
Dialysis Services and Supplies
Part B covers outpatient dialysis treatments and doctor’s services. It also covers training, equipment, and supplies for home dialysis, some home care services from a dialysis facility, and some drugs for outpatient and home dialysis.
You must first pay the Part B deductible ($257 in 2025) OOP, after which you’ll be liable for a 20% copayment. Dialysis can cost upwards of $500 per session without insurance, and many dialysis patients need multiple sessions per week.
Putting It All Together
Navigating end-stage renal disease can be a complicated and heavy process, and without the right health insurance, it can also be extremely costly. Medicare helps pay for dialysis treatments and kidney transplants for ESRD patients of all ages. Consider working with a licensed insurance agent or broker to determine whether you’re eligible for Medicare based on an ESRD diagnosis and choose the best plan to support your treatment.
FAQs
Will Medicare cover my kidney transplant?
Do I have to pay for Medicare Part A and Part B?
People on dialysis at any age will pay a standard monthly Part B premium. Some people will pay a higher premium based on their income.
What is Medigap, and can I get this policy if I have ESRD?
Not all private insurers will sell Medigap to people under age 65, even if they have end-stage renal disease. Medigap rules vary from state to state, and if you are under 65 and receive this policy, you may pay more because of your age.
Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. Also, you will have to pay a premium to the Medigap insurance company.
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Sources
Medicare’s Coverage of Kidney Dialysis & Kidney Transplant Benefits. Medicare.gov
Kidney Disease Statistics for the United States. NIH.gov
Supporting Medigap reform. American Kidney Fund.
2020 U.S. organ and tissue transplants: Cost estimates, discussion, and emerging issues. Milliman Research Report.
How Much Does Dialysis Cost? GoodRX.com