Medicare typically covers care deemed medically necessary by a qualified healthcare provider.
You can qualify for Medicare no matter how old you are if you have end-stage renal disease (ESRD), permanent kidney failure requiring dialysis or a kidney transplant, and meet other qualifications set forth by Medicare. If you have Medicare and need a kidney transplant, it will be covered if it’s done in a hospital that’s Medicare-certified to do kidney transplants.
ESRD is an advanced kidney disease that occurs when the kidneys stop functioning permanently, and you need dialysis and/or a kidney transplant to maintain life.
In order to receive the full benefits (including dialysis) if you have ESRD, you must have Medicare Part B and pay the monthly premium each month. You qualify for Part B if you’ve worked long enough to qualify for Medicare.
If you have ESRD, Medicare can help pay for treatment costs, plus some (or even all) costs associated with hospital stays, doctor visits, kidney dialysis and kidney transplants.
Medicare coverage for kidney transplants
If you need a kidney transplant, most of the services and supplies you need will be covered by Medicare Part A or Part B, as long as the services take place in the Medicare-certified hospital where you’ll get your transplant, or another hospital that participates in Medicare.
Part A covers:
- Inpatient services
- Kidney registry fee
- Laboratory and other tests needed to evaluate your medical condition, and the condition of potential kidney donors
- The costs of finding the proper kidney for your transplant surgery (if there is no donor)
- The full cost of care for your kidney donor (including care before, during and after surgery)
- Blood (whole or units of packed red blood cells, blood components, and the cost of processing and giving you blood)
Part B covers:
- Doctors’ services for kidney transplant, including care before, during and after the surgery
- Doctors’ services for your kidney donor during their hospital stay
- Transplant drugs (also known as immunosuppressive drugs) for a limited time after you leave the hospital
Transplant Drugs Coverage
Transplant drugs, or immunosuppressants, are given to you after a transplant surgery to help reduce the risk of your body rejecting your new kidney. You’ll need to take these drugs for the rest of your life. Medicare Part B will cover transplant drugs after a covered transplant.
If you’re eligible for Medicare only because of permanent kidney failure, your Medicare coverage of the drugs will end 36 months after the month of the transplant.
Otherwise, Medicare will pay for your transplant drugs with no time limit if one of these conditions applies:
- You were already eligible for Medicare due to age or a disability before you were diagnosed with ESRD
- You became eligible for Medicare because of age or disability after getting a transplant that Medicare paid for, or you had private insurance that paid primary to your Part A coverage
Part D drug coverage
Even though immunosuppressant drugs are covered by Part B, other prescription medications you may need will only be covered by Part D. You must have Medicare Part D, or other creditable drug coverage for prescription drugs, or face paying a late enrollment penalty or other fees.
Note: If you did not have Part A when you received a transplant, your immunosuppressant drugs will be covered by Part D.
Part D covers most outpatient prescription drugs. This coverage is offered through private companies as either a stand-alone plan you purchase separately, or as an included benefit with a Medicare Advantage plan.
Each Part D plan has a list of covered drugs in its formulary. When choosing a drug plan, make sure any prescription drugs you currently take are listed on the formulary. Otherwise, you may have to pay for the cost completely out of pocket.
Medicare Dialysis Coverage
There are two types of dialysis treatment options that help clean your blood when your kidneys don’t work by getting rid of waste, extra salt and built-up fluids in your body, as well as help to control blood pressure. While it’s not a cure for permanent kidney failure, it may help you feel better.
You can get covered dialysis at:
- A Medicare-certified dialysis facility, where a nurse or trained technician may give you the treatment. In most cases, it’s the same facility where your kidney doctor works.
- A hospital, if you’re admitted and need dialysis during a covered inpatient hospital stay.
- Home, where you’ll receive training for home dialysis by a facility certified by dialysis training.
Original Medicare Part A and Part B cover much of what you’ll need for dialysis.
Part A covers:
- Inpatient dialysis treatment (if you’re admitted to the hospital for special care)
Part B covers:
- Outpatient dialysis treatment and doctors’ services (in a Medicare-certified dialysis facility or your home)
- Home dialysis training (which includes instruction for you and anyone helping you with your home dialysis treatments)
- Home dialysis equipment and supplies (such as the machine, water treatment system, basic recliner, alcohol, wipes, sterile drapes, rubber gloves and scissors)
- Certain home support services (such as visits by trained hospital or dialysis facility workers to check in, help in case of an emergency, etc.)
- Most drugs for outpatient or home dialysis
- Other services and supplies that are part of dialysis (such as lab tests)
What is not covered?
There are some things Original Medicare does not cover when it comes to dialysis, such as:
- Paid dialysis aides to help you with home dialysis
- Any lost pay to you or those helping you during home dialysis training
- A place to stay during your treatment
- Blood or packed red blood cells for home dialysis (unless part of a doctor’s service)
Medicare after a kidney transplant
If your transplant is successful, which means it lasts for 36 months without rejection, your Medicare ESRD coverage will end, meaning you will no longer be covered for dialysis and other treatments.
However, it can resume if within 36 months of your transplant, you have to start dialysis again or have another transplant.
If you had Medicare before being diagnosed with ESRD, your Part A and Part B coverage will continue with normal beneficiary coverage.
Even with Medicare Part A and Part B coverage, there are some costs you will have to pay out-of-pocket related to a kidney transplant and/or kidney dialysis.
While in most cases you won’t have a monthly premium for Part A (because you paid Medicare taxes while working), you will have to pay the monthly Part B premium of $164.90. You’ll also have to meet your Part A annual deductible, which is $1,600 (if applicable) and your Part B annual deductible, which is $226 (in 2023).
Specific costs for transplant facilities vary.
How much does Medicare pay for dialysis?
Under Part B coverage, Medicare will pay your dialysis facility for these services:
- Direct nursing services
- All equipment and supplies you need for renal dialysis
- Injectable, IV, and certain oral drugs used to treat or manage conditions of ESRD
- Lab tests
- Home dialysis training (if applicable)
- Other items and services you need during dialysis treatments
Your dialysis facility must provide these items and services. Depending on where you get your dialysis treatments, you may have other out-of-pocket costs.
Dialysis in a dialysis facility
After you meet your Part B deductible, you’ll pay 20% coinsurance of the Medicare-approved amount for all covered, dialysis-related services. (Medicare will pay the other 80%.)
Dialysis in a hospital
- Inpatient: If you’re admitted to a hospital and get dialysis, Part A will cover your treatments as part of the cost of your covered inpatient hospital stay. In this case, your coinsurance will depend on how many days you stay in the hospital.
- Outpatient: After you meet your Part B deductible, you’ll pay 20% coinsurance.
Dialysis at home
Original Medicare will pay your kidney doctor a fee to supervise your home dialysis training. After you meet the Part B deductible, you’ll pay 20% coinsurance and Medicare will pay the remaining 80%.
How much does Medicare pay for kidney transplant services?
If you have Original Medicare, you’ll first have to meet your Part A deductible ($1,600 in 2023). Then, you’ll pay a coinsurance for each benefit period:
- Days 1-60: $0 coinsurance
- Days 61-90: $400 coinsurance per day
- Days 91 and beyond: $800 coinsurance per each “lifetime reserve day” after day 90
However, Medicare will pay the full cost of care for your kidney donor, including care before, during and after the surgery. Neither you nor the donor will have to pay a deductible, coinsurance or other costs for their care.
When it comes to doctors’ services once you meet your Part B deductible, you’ll be responsible for 20% coinsurance, and Medicare will pay the other 80%.
You do not have to pay anything for Medicare-approved lab tests.
How much does Medicare pay for blood services?
In most cases, the hospital will get blood from a blood bank at no charge, so you won’t have to pay for it or replace it. Part A and Part B help pay for whole blood units or packed red blood cells, blood components, and the cost of processing and giving you blood.
However, if the hospital has to buy blood for you, you must either pay the hospital back for the first three units of whole blood you get in a calendar year, or replace the blood by donating it yourself or having another person donate for you.
How to apply for Medicare
To enroll in Medicare, you can:
- Apply online at www.ssa.gov
- Visit your local Social Security office
- Call Social Security
- Call the Railroad Retirement Board (RRB) (if you worked for a railroad)
- If you already have Part A and want Part B, you must complete an Application for Enrollment in Part B
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