Medicare for Children with End-Stage Renal Disease

Who Should Read This

This publication is written for parents and legal guardians of children under age 18 who have been diagnosed with End-Stage Renal Disease (ESRD), the permanent loss of kidney function requiring dialysis or a kidney transplant to survive. It is also valuable for adult caregivers, social workers, hospital discharge planners, and pediatric nephrologists who help families navigate health insurance options after an ESRD diagnosis.

Because Medicare eligibility is typically tied to age or disability, many families are surprised to learn that children with ESRD can qualify for Medicare regardless of age. This publication explains that pathway clearly and walks families through what comes next.

Quick Overview

This CMS publication explains how children diagnosed with ESRD can qualify for Medicare and what families need to do to enroll. It covers eligibility rules, how Medicare works alongside other insurance a child may already have, what Medicare pays for, and how to get started. The original document is a brief, plain-language guide designed to be accessible for families who may be unfamiliar with Medicare.

Key Takeaways

• Children of any age with ESRD can qualify for Medicare if a parent or the child themselves has enough Social Security or Railroad Retirement work credits.
• Medicare coverage for children with ESRD is not automatic — families must apply through the Social Security Administration.
• There is a 3-month waiting period before Medicare coverage begins, starting the month dialysis begins.
• If a child receives a kidney transplant, Medicare coverage may continue for a limited period after the transplant.
• Medicare will coordinate benefits with any other health insurance the child has, such as a parent's employer plan.
• Families should contact Social Security as soon as possible after a child's ESRD diagnosis to avoid gaps in coverage.
• Children who qualify for Medicare based on ESRD may also be eligible for Medicare Supplement (Medigap) insurance to help cover out-of-pocket costs.

Publication Summary

When a child is diagnosed with End-Stage Renal Disease, the medical costs can be overwhelming almost immediately. Dialysis alone can cost tens of thousands of dollars per year, and a kidney transplant involves even greater expenses. Medicare exists as a federal health insurance program that can step in to cover many of these costs — even for children — when certain conditions are met.

Who Qualifies

A child with ESRD can qualify for Medicare if the child, a parent, or a spouse has worked long enough under Social Security or the Railroad Retirement system to be insured. This work history requirement does not have to come from the child — a parent's work record is enough. Once eligibility is confirmed, Medicare coverage is available to children of any age, from infants through teenagers.

The Waiting Period

Medicare coverage for ESRD does not begin immediately. There is a 3-month waiting period that starts the month a child begins regular dialysis. This means coverage typically starts in the fourth month of dialysis. However, if a child participates in a self-dialysis training program at home, the waiting period may be waived and coverage can begin sooner. Families need to plan carefully during this waiting period to ensure their child's dialysis costs are covered through other means, such as a parent's private health insurance.

What Medicare Covers

Once active, Medicare covers the treatments and services children with ESRD need most, including dialysis (in a dialysis center or at home), kidney transplants, immunosuppressive drugs needed after a transplant, and related hospital and doctor visits. Medicare is divided into parts, and understanding how those parts work together is important for families managing a child's care.

Medicare Part A covers inpatient hospital stays, including the hospital costs associated with a kidney transplant. Medicare Part B covers outpatient services, including dialysis treatments at a certified dialysis facility, doctor visits, lab work, and certain drugs administered during dialysis. Part B requires payment of a monthly premium, and families should be aware of this ongoing cost.

Coordination With Other Insurance

Many children with ESRD already have health insurance through a parent's employer. When a child has both Medicare and another health plan, the plans must coordinate benefits — meaning one plan pays first and the other pays second. During the first 30 months of Medicare eligibility for ESRD, the employer plan is typically required to pay first, and Medicare pays second. After 30 months, Medicare becomes the primary payer. This coordination period is important for families to understand, as it affects how claims are processed and how much the family may owe out of pocket.

After a Transplant

If a child receives a successful kidney transplant, Medicare coverage does not end immediately. Medicare will continue to cover immunosuppressive drugs — the medications needed to prevent the body from rejecting the new kidney — for a specific period after the transplant. Families should understand this timeline and plan for how these medications will be covered once the Medicare coverage period ends, as these drugs must be taken for life.

How to Apply

Families apply for Medicare through the Social Security Administration, not through Medicare directly. The application can be completed in person at a local Social Security office, by phone, or online at ssa.gov. Families should apply as soon as the child is diagnosed with ESRD and begins or is about to begin dialysis. Having the child's medical records and the parent's Social Security information available will help speed up the process.

Frequently Asked Questions

Does my child have to be a certain age to qualify for Medicare based on ESRD? No. There is no minimum age requirement. Infants, toddlers, school-age children, and teenagers can all qualify for Medicare if the ESRD eligibility requirements are met through the child's own, a parent's, or a spouse's work history under Social Security or Railroad Retirement.

When does Medicare coverage actually start? Coverage generally starts in the fourth month after regular dialysis begins, due to a 3-month waiting period. If the child is enrolled in a home dialysis training program, coverage may begin sooner — potentially as early as the first month dialysis begins.

What happens to Medicare coverage after a kidney transplant? After a successful transplant, Medicare will continue to cover immunosuppressive drugs for a defined period. Families should speak with a Medicare counselor to understand exactly when this coverage ends and what options exist afterward.

What if my child already has health insurance through my job? Medicare will coordinate with your employer health plan. For the first 30 months of Medicare eligibility, your employer plan pays first and Medicare pays second. After 30 months, Medicare becomes the primary payer. It is important to notify both your employer's plan and Medicare of the child's coverage to ensure claims are processed correctly.

Where do I apply for Medicare for my child with ESRD? Applications are made through the Social Security Administration. You can apply online at ssa.gov, call 1-800-772-1213, or visit your local Social Security office.

Access the Full Publication

Publication number: CMS Product No. 11392
Publisher: Centers for Medicare & Medicaid Services (CMS)
Length: 4 pages