When your kidneys can no longer function naturally, your body enters into ESRD. Dialysis is a treatment to help your body function by cleaning your blood when your kidneys stop functioning on their own.
Along with helping your body retain the correct amount of fluids and controlling blood pressure, dialysis helps eliminate harmful waste, fluids, and salt that build up in your body. Although they may help you live longer and feel better, dialysis treatments are not a cure for permanent kidney failure.
Keep reading to learn more about Medicare’s dialysis and treatment coverage, including eligibility and cost.
The eligibility requirements for Medicare are different if your eligibility is based on ESRD.
If you don’t enroll right away
If you’re eligible for Medicare based on ESRD but miss your initial enrollment period, you may be eligible for retroactive coverage of up to 12 months, once you’ve enrolled.
If you’re on dialysis
If you enroll in Medicare based on ESRD and you’re currently on dialysis, your Medicare coverage usually begins on the 1st day of your dialysis treatment’s 4th month. Coverage can start the 1st month if:
- During the first 3 months of dialysis, you participate in home dialysis training at a Medicare-certified facility.
- Your doctor indicates that you should finish training so you can do your own dialysis treatments.
If you’re getting a kidney transplant
If you’re admitted to a Medicare-certified hospital for a kidney transplant and the transplant takes place that month or in the next 2 months, Medicare can begin that month.
Medicare coverage can begin 2 months before your transplant if the transplant is delayed more than 2 months after being admitted to the hospital.
If you’re only eligible for Medicare due to permanent kidney failure, your coverage will stop:
- 12 months after the month dialysis treatments are stopped
- 36 months following the month you have a kidney transplant
Medicare coverage will resume if:
- within 12 months after the month, you stop getting dialysis, you start dialysis again or have a kidney transplant
- within 36 months after the month you get a kidney transplant you get another kidney transplant or start dialysis
Original Medicare (Part A hospital insurance and Part B medical insurance) covers many of the supplies and services needed for dialysis, including:
- inpatient dialysis treatments: covered by Medicare Part A
- outpatient dialysis treatments: covered by Medicare Part B
- outpatient doctors’ services: covered by Medicare Part B
- home dialysis training: covered by Medicare Part B
- home dialysis equipment and supplies: covered by Medicare Part B
- certain home support services: covered by Medicare Part B
- most drugs for in-facility and at-home dialysis: covered by Medicare Part B
- other services and supplies, such as laboratory tests: covered by Medicare Part B
Medicare should cover ambulance services to and from your home to the closest dialysis facility if your doctor provides written orders certifying that it’s a medical necessity.
Services and supplies not covered by Medicare include:
- payment for aides to help with home dialysis
- lost pay during home dialysis training
- lodging during treatment
- blood or packed red blood cells for home dialysis (unless included with a doctor’s service)
Medicare Part B covers injectable and intravenous drugs and biologicals and their oral forms provided by the dialysis facility.
Part B does not cover medications that are available only in oral form.
Medicare Part D, which is purchased through a Medicare-approved private insurance company, offers prescription drug coverage that, based on your policy, typically covers this type of medication.
If you get dialysis after being admitted to a hospital, Medicare Part A covers the costs.
Outpatient doctors’ services are covered by Medicare Part B.
You’re responsible for premiums, yearly deductibles, coinsurance, and copays:
- The annual deductible for Medicare Part A is $1,408 (when admitted to a hospital) in 2020. This covers the first 60 days of hospital care in a benefit period. According to the U.S. Centers for Medicare & Medicare Services, about 99 percent of Medicare beneficiaries do not have a premium for Part A.
- In 2020, the monthly premium for Medicare Part B is $144.60 and the annual deductible for Medicare Part B is $198. Once those premiums and deductibles are paid, Medicare typically pays 80 percent of the costs and you pay 20 percent.
For home dialysis training services, Medicare typically pays a flat fee to your dialysis facility to supervise home dialysis training.
After the Part B yearly deductible is met, Medicare pays 80 percent of the fee, and the remaining 20 percent is your responsibility.
Most treatments, including dialysis, that involve end stage renal disease (ESRD) or kidney failure are covered by Medicare.
The details regarding coverage of treatments, services and supplies, and your share of the costs can be reviewed with you by your health care team, which includes:
- social workers
- dialysis technicians
For more information consider visiting Medicare.gov, or calling 1-800-MEDICARE (1-800-633-4227).
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