What Does Medicare Cover for Anemia?

You can get coverage for anemia through Medicare — as long as the services your doctor recommends for anemia are considered medically necessary by Medicare.

Generally, Medicare considers services medically necessary if they’re both:

• being used to diagnose, treat, or prevent a medical condition
• approved and proven treatments for the condition

That means that Medicare is unlikely to pay if your doctor recommends an experimental treatment for your anemia diagnosis. However, you’ll have coverage for any standard treatments.

Medicare might want to see documentation from your doctor verifying that you’ve been diagnosed with anemia and need the prescribed treatment.

End stage renal disease (ESRD) and anemia coverage

People who have end stage renal disease are at high risk for anemia. Both those undergoing dialysis and those who’ve recently had a kidney transplant are frequently diagnosed with anemia.

People of all ages who have ESRD are eligible for Medicare.

In fact, when you’ve been diagnosed with ESRD, your Medicare coverage will start right away. You won’t have the 2-year waiting period that’s typically required to qualify for Medicare when you’re under age 65.

If you’re eligible for Medicare because of your ESRD diagnosis and have anemia, Medicare will cover your treatments. Those treatments might differ from standard treatments because of your ESRD.

For example, when you have ESRD, you might not have enough of a hormone called erythropoietin (EPO). EPO is made in your kidneys and it tells your body to make more red blood cells when the old ones die.

If you don’t have enough of this hormone, you also won’t have enough red blood cells. You’ll need a prescription for an erythropoiesis-stimulating agent (ESA) to help your body make the red blood cells it needs.

Medicare will cover ESAs since they’re medically necessary to treat anemia caused by ESRD.

Anemia happens when there aren’t enough red blood cells in your body.

Without the right amount of red blood cells, your body doesn’t get the oxygen it needs. This can cause you to feel weak and tired.

You might also experience symptoms such as:

• shortness of breath
• pale or yellowed skin
• light-headedness
• headache
• racing pulse
• cold hands and feet

Anemia is the most common blood disorder, and it affects more than 3 million Americans. There are multiple types of anemia, including:

• Iron-deficiency anemia. Iron-deficiency anemia is the most common type of anemia. Generally, it occurs due to blood loss, such as after surgery or an accident. It can also happen when your body has trouble absorbing the iron it needs.
• Vitamin-deficiency anemia. People with this type of anemia are low in important vitamins like B12 and folic acid. This normally happens when you don’t get enough vitamins in your diet, but can also happen if your body has trouble absorbing the vitamins.
• Hemolytic anemia. In hemolytic anemia, your red blood cells break apart in your bloodstream. This can be caused by infections, autoimmune disorders, or abnormalities in your heart.
• Sickle cell anemia. Sickle cell anemia is an inherited disorder that affects the hemoglobin protein your body makes. This causes your red blood cells to flow through your blood vessels incorrectly and can lead to blockages that interrupt your circulation.
• Anemia caused by other conditions. Anemia can be caused by another condition, like ESRD. Some people also develop anemia after chemotherapy to treat cancer.
• Aplastic anemia. Aplastic anemia is a rare kind of anemia that occurs when your bone marrow doesn’t make enough blood cells. This can happen due to serious infection or exposure to toxic substances.

Treatment will look different for each type of anemia. However, Medicare will cover you no matter what kind of anemia you have.

As long as the treatments your doctor prescribes are proven to be effective at treating anemia, you’ll have coverage.

Medicare will cover you during your anemia diagnosis. Anemia is generally diagnosed through a blood test called a complete blood count (CBC).

Your doctor will order a CBC if you have any of the symptoms of anemia. They might also order this test if you’re at high risk because you have a condition such as ESRD or you’ve recently had an injury or infection that could affect your blood.

Medicare always covers diagnostic tests. This includes the CBC test for anemia. Medicare will also cover any additional tests your doctor orders to confirm your diagnosis.

Your treatment for anemia will depend on the kind of anemia you have. In mild cases, you might be able to treat your anemia with dietary changes.

Your doctor might recommend you eat more foods that can help your body get the iron, vitamin B12, or folic acid it needs. In other cases, you might need more complex treatment.

Some treatments covered by Medicare include:

• Iron supplements. Iron supplements treat iron-deficiency anemia. To get coverage, you’ll need a Medicare plan that includes prescription coverage. This includes all Medicare Part D plans and many Medicare Advantage plans.
• Vitamin supplements. You might need to take vitamin B12 or folic acid supplements to treat vitamin-deficiency anemia. Just like iron supplements, you’ll need a Part D or Advantage plan for coverage.
• Iron or B12 injections. Your doctor might order an injection if your body can’t absorb the iron or vitamin B12 you need. You’ll generally get these treatments at your doctor’s offices. Medicare will cover them as long as your doctor verifies that supplements haven’t helped you.
• ESA injections. ESA injections help your body make red blood cells when your kidney is unable to. You’ll receive these injections at your doctor’s office. Medicare will cover ESA injections if your anemia is caused by kidney failure.
• Infusions. You might need an IV infusion if you’ve had blood loss, if your body can’t absorb iron, or if you have ESRD. Medicare will pay for infusions if your doctor verifies that supplements aren’t working for you.
• Blood transfusions. Sometimes a blood transfusion is needed to help your anemia. Medicare will cover the transfusion costs, and generally pints of blood are donated and free. However, if there is a cost for pints of blood, you might be responsible.

Other treatments will depend on your anemia.

For example, if your anemia is caused by a heart condition, you’ll need treatments that help your heart. If your anemia is caused by your bone marrow, you might need a bone marrow transplant.

Medicare will cover those treatments as long as they’re medically necessary.

Your anemia treatment might include several parts of Medicare. It’s a good idea to know what parts you have and what each part will cover for your anemia diagnosis.

Here’s a breakdown of the Medicare parts:

• Part A. Medicare Part A is hospital insurance. It’ll cover you if you need to stay at a hospital or other inpatient facility during your anemia treatment — for example, if you need to be hospitalized for a blood transfusion.
• Part B. Medicare Part B is medical insurance. It pays for services such as doctor visits, ambulance rides, and the emergency room. It’ll cover services like your doctor’s office visits, diagnostic blood tests, and B12 or iron injections.
• Part C. Medicare Part C is also known as Medicare Advantage, and it covers everything that original Medicare (parts A and B) does. Advantage plans often also include coverage beyond original Medicare. Many Advantage plans include prescription drug coverage as well.
• Part D. Medicare Part D is prescription drug coverage. You’ll need this coverage for iron, vitamin B12, or folic acid supplements.
• Medigap. Medigap is Medicare supplement insurance. These plans help cover the out of pocket costs of using original Medicare. Some Medigap plans also cover the costs of pints of blood.

Tips for choosing a Medicare plan if you have anemia

• Make sure you have prescription drug coverage.
• Compare the costs of Part D and Advantage plans in your area.
• Check the formulary (list of covered drugs) of Part D and Advantage plans to make sure the supplements you need are included.
• Consider a Medigap plan if you think you might need blood transfusions.

Medicare will cover the diagnosis and treatment of anemia. There are multiple types of anemia, and your treatment will depend on which kind you have.

Medicare will cover your treatments for all types as long as the treatment is medically necessary. It’s a good idea to have a prescription drug plan, especially if you know you’ll need supplements to treat your anemia.