Medicare covers most services considered medically necessary when they're ordered by a qualified healthcare provider.
Thankfully, the answer to this question is simple: Yes, Medicare does cover kidney dialysis. This is true whether you're undergoing hemodialysis, peritoneal dialysis, or some other form of dialysis at your dialysis facility.
Medicare health coverage for end-stage renal disease (ESRD) can be somewhat complex. Although most people will have coverage, understanding eligibility for ESRD Medicare benefits is a bit more complicated than usual. This is because Medicare has different qualifications for healthcare coverage for those who have ESRD, so the guidelines differ. However, if you have Medicare, rest assured that your dialysis will be covered.
Medicare Enrollment with End-Stage Renal Disease
Medicare has different enrollment guidelines for dialysis patients. Unlike the traditional way of getting Medicare, which happens when you turn 65, you can actually get Medicare at any age if you have ESRD. However, a few conditions do apply.
On the medical side, it must be the case that your kidneys no longer work, and you need dialysis or a kidney transplant. In addition to this, you must have either worked the required amount of time under Social Security or for the government, already be eligible for Social Security or be the spouse or dependent of someone who fulfills one of these conditions.
If you fulfill these conditions, you should be able to get Medicare coverage, no matter your age. If you want more information or to double-check your eligibility, you should contact Social Security, as they’ll be able to provide you with more details about eligibility and enrollment.
When Does Coverage Start?
Medicare coverage for ESRD can be retroactive. This means that you may get coverage for some time before you enroll in Medicare. Coverage can start an entire year before you actually enroll. This means that if you become eligible for Medicare in January due to fulfilling all of the above-listed conditions, but only actually enroll in October, your coverage will retroactively apply from January.
If you are on dialysis, Medicare coverage will usually start in the fourth month of your treatment. If you start dialysis in January, your coverage will begin in April. This still takes retroactive coverage into account: if your coverage begins in April, you will be covered from April onward, even if you only enroll in October.
Speed Things Up with Home Dialysis Training
There is a way to get coverage earlier than the fourth month of your dialysis. Your coverage can begin in the first month of your dialysis if you participate in a Medicare-approved dialysis training program, and your doctor thinks that you’re in a position to do dialysis treatments on your own. If you fulfill both of these requirements, then your dialysis treatment can be covered much sooner.
When Does Coverage Start for Kidney Transplants?
Kidney transplants have a slightly different coverage structure. If you’re going to have a kidney transplant, your Medicare coverage will begin that month. If your transplant is delayed, you’ll still be covered during the delay period. If you are admitted to a hospital to undergo some procedures that are related to your kidney transplant, then your coverage will begin in time to cover those procedures, not just the kidney transplant itself. Your coverage can begin up to two months before the transplant itself.
Because of this, the one instance that this can get tricky is if you’re admitted to a hospital for tests and then your transplant is delayed. For example, if you are admitted for pre-transplant procedures and tests on January 1st, and your transplant is scheduled for February 1st but then delayed until June 1st, then your kidney transplant coverage will begin in April, two months earlier. In this case, your initial procedures may not be covered.
When Is My Coverage Over?
If you have Medicare health insurance specifically due to your dialysis or kidney transplant, but don’t fulfill other enrollment triggers, then your coverage will eventually end. If you are undergoing dialysis, Medicare coverage will end 12 months after your last dialysis treatment. In the case of transplant, it will be 36 months after your transplant.
If you begin dialysis again, or if you have a kidney transplant after initially being on dialysis within 12 months of stopping, your coverage will begin again. If you had a kidney transplant and have another, or begin dialysis within 36 months of the initial transplant, your coverage will begin again as well.
How Does Coverage Work Overall?
As you may know, Medicare is divided into different parts. Each part of Medicare covers a different type of medical costs, so it’s useful to understand how each of these will cover different parts of your ESRD-related treatment costs. Coverage differs from ordinary Medicare in some regards, especially regarding prescription drugs.
Medicare Part A and ESRD
Medicare Part A usually covers your hospital or inpatient health costs and is often referred to as hospital insurance. Part A is part of Original Medicare, which is what most people automatically enroll in at age 65. For most, there is no monthly premium.
Medicare Part A will pay for your inpatient dialysis treatment if it is done in an inpatient setting, like a hospital. Medicare Part A has a deductible of $1,600, which you must pay before coverage begins. After that, you must still pay a coinsurance fee for your hospital stays.
For the first 60 days per benefit period, you won’t pay anything at all once your deductible is met. For days 61-90, you’ll pay a $400 per day coinsurance. For days 91 and beyond, you’ll pay $800 per day, and use one “lifetime reserve day” for each day you remain in the hospital. These days do not reset at the end of each benefit period.
If you aren’t admitted as an inpatient, your dialysis costs won’t be covered by Part A.
Dialysis Coverage under Medicare Part B
Part B Medicare plans cover medically necessary outpatient care and will usually cover your outpatient dialysis services. This will be true whether it’s in a dialysis center or self dialysis at home. Medicare Part B usually covers durable medical equipment and will cover your home dialysis equipment. It will also cover most other outpatient procedures related to your kidney disease, such as laboratory tests.
The Part B deductible is quite low at $226. Unlike Part A, most people pay monthly premiums for Part B. These are income-adjusted, so you pay more if you earned more in the relevant tax period. The standard Part B premium is $164.90 per month in 2023. If your modified adjusted gross income (MAGI) is over $97,000 (filing single) or $194,000 (married filing jointly), you may have to pay the Income-Related Monthly Adjustment Amount (IRMAA). Fewer than 5% of enrollees owe this surcharge.
After you pay your deductible, you will have a coinsurance of 20 percent. This means that although your dialysis and other health needs will be covered, you will still pay 20 percent of the health care costs, while Medicare pays the remainder. There are some medical services for which you won’t pay a coinsurance, but you will usually pay this 20 percent for dialysis treatment.
Prescription Drug Coverage Under Part B
Part B usually doesn’t cover any self-administered prescription drugs. However, it will cover prescription drugs that are directly related to your dialysis treatment. If you have additional health conditions that require prescription drug use but aren’t directly related to your dialysis treatment, then you’ll need to seek additional prescription drug coverage.
Medicare Advantage (Part C): What Does it Cover?
Medicare Advantage plans, also known as Part C health plans, offer a way to get your Medicare coverage through a private insurance company. Part C plans are private, and therefore vary in price and slightly vary in coverage. However, according to CMS regulations, all Part C plans must cover dialysis just like Original Medicare does.
If you have a Part C plan, your dialysis coverage will function very similarly to how it does under Original Medicare. You should always check with your plan for information about the provider network and other coverage details. However, your plan will never be allowed to charge more than Medicare does for dialysis, so keep that in mind.
Part D Prescription Drug Plans
Part D plans cover prescription drugs and are administered by private insurance companies. For this reason, plans will vary in cost and coverage. If you have prescription drug needs and can get Medicare due to ESRD, you may want to find a suitable Part D plan to help cover any non-dialysis related drug costs that you have.
If you do this, make sure to look at the plan's formulary (list of covered drugs) and coverage amounts, to ensure that what you need will be covered. Although Part D plans are regulated by the government to some degree, you should treat these plans as private medical insurance plans, and analyze them as such.
Additional Financial Help Options
If you want additional financial help with your health care costs, there are additional options for you. Medigap plans, also known as Medicare Supplement plans, offer a way to cover many of the out-of-pocket costs associated with Medicare. With these plans, you'll pay a monthly premium, but have many of your out-of-pocket costs covered, depending on which plan you choose.
In addition to this, if you are eligible for Medicaid, you'll often be eligible for additional extra help programs and support services that can reduce your costs. These plans tend to vary between states, so the best way to find out more information is to contact Medicaid for more information.
If you’re familiar with Medicare, understanding how Medicare eligibility works for dialysis can be confusing. The good news is that Medicare will have you covered in most instances when you're undergoing kidney failure, even if it can be tricky to understand enrollment.
As always, the important thing is to be knowledgeable about your coverage, so you know what’s coming at every stage and can manage your benefits to best suit your needs. If you need more information about Medicare coverage for dialysis and ESRD in general, this page from medicare.gov has many more details about things like the 30-month coordination period and payment options.
I Have End-Stage Renal Disease (ESRD)
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Medicare Coverage of Kidney Dialysis & Kidney Transplant Services
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ESRD Medicare: What to Know
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