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Kidney failure, medically referred to as end-stage renal disease (ESRD), often requires patients to undergo dialysis, either in their own home or at a dialysis facility. Either way, it’s important to know what kind of coverage you get under Medicare if you require dialysis.
Keep in mind that you generally have a few options when it comes to how you get your Medicare benefits, and your dialysis costs may be different depending on the type of coverage you have. One option is to enroll in Original Medicare (Part A and Part B) and add on Medicare Part D prescription drug coverage with a stand-alone Medicare Prescription Drug Plan.
If you have end-stage renal disease, you’re generally not eligible to enroll in a Medicare Advantage plan (Medicare Part C). This is a type of plan offered through private insurance companies approved by Medicare that provides at least the same level of benefits as Original Medicare and may cover additional benefits, such as routine vision, dental, or prescription drugs. There are some exceptions where you can enroll in a Medicare Advantage plan if you have ESRD.
Even if you’re not eligible for a Medicare Advantage plan, you may be eligible for a Special Needs Plan, a specific type of Medicare Advantage plan that targets individuals who live in an institution, have Medicaid, or have certain chronic conditions (such as ESRD). These plans include prescription drug coverage as part of the plan, and a Chronic-Condition Special Needs Plan for people with ESRD may also cover certain services to help you manage your condition. If there is a Special Needs Plan for beneficiaries with end-stage renal disease in your area, you may be able to enroll and get your Medicare benefits that way.
The information contained in this article is for informational purposes only. It should never be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition.
People with end-stage renal disease may require dialysis. According to the National Kidney Association, dialysis replaces kidney function by removing waste and excess fluid from the body. Dialysis also helps manage blood pressure, increase red blood cell levels, and maintain healthy levels of vitamins and minerals that your body needs.
There are two main types of kidney dialysis: hemodialysis and peritoneal dialysis. During hemodialysis, your blood flows out through a special filter connected to a machine that cleans waste from your body. During peritoneal dialysis, the patient is hooked up to a tube that transfers a cleansing solution into the abdomen. The solution helps absorb waste and excess fluid. After a certain length of time, the solution is then drained from the body, taking the waste with it. The benefit of peritoneal dialysis is that you can be trained to perform the treatment at home.
If your doctor decides that hemodialysis is the best treatment option for you, you can choose between traditional hemodialysis in a dialysis facility/center, called “in-center hemodialysis,” or home hemodialysis. If your doctor determines that peritoneal dialysis may be a better treatment option, you will be trained to perform dialysis at home.
Whether you choose home hemodialysis or peritoneal dialysis, you will typically have to visit a dialysis center periodically to check in with your dialysis care team and review your lab results.
According to the National Kidney Association, the types of in-center hemodialysis treatment options may include traditional in-center hemodialysis and in-center nocturnal hemodialysis. Each is a little different:
Dialysis can be done at home if you’re eligible for self-dialysis and receive doctor approval. You can also receive treatment in a Medicare-certified dialysis facility. For Medicare to pay for your treatments, the dialysis facility must be certified by Medicare.
When deciding where to get dialysis, you have the right to choose a dialysis facility and to later select a different facility if you’re not happy with your original choice. You can also review the quality ratings of dialysis clinics near you on Medicare’s Dialysis Facility Compare.
Medicare Part A covers inpatient dialysis treatment if you receive that care in a Medicare-approved hospital.
Medicare Part B pays for these services and items:
Medicare Part D (prescription drug coverage) covers medications that are only available in oral form, such as those that only come in tablet, liquid, or capsule form. Talk with your doctor or health care team about the use of any prescription drugs, including over-the-counter products.
Medicare doesn’t cover:
Keep in mind that if you only have Medicare due to end-stage renal disease (that is, you’re not over 65 or disabled), your Medicare coverage will end 12 months after the month you stop dialysis or 36 months after the month that you get a kidney transplant.
If you have Original Medicare, you’ll continue to pay 20% of the Medicare-approved amount for all covered outpatient dialysis-related services, including those related to self-dialysis. Medicare will pay the remaining 80%. The Medicare Part B deductible applies.
If you’re in a Medicare Advantage plan (like an HMO or PPO), then your costs may be different. Read your plan materials or call your benefits administrator to get your cost information.
You must also continue to pay your monthly Medicare Part B and Part D premiums, if applicable.
You can still travel within the United States if you’re on dialysis. You should work with your dialysis facility to plan how you will continue to get dialysis treatment during your trip. Your dialysis facility can also help you confirm that the dialysis facilities on your trip:
Medicare will typically only pay for hospital or medical care that you get in the United States, except in a few specific instances. If you need emergency dialysis, Medicare may cover your dialysis treatment at a hospital. Health care you get “in the United States” includes the 50 states, the District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, Northern Mariana Islands, and American Samoa. Apart from these areas, Medicare generally won’t cover health care services you get outside of the country.
If you get your dialysis services from a Medicare Advantage plan, such as a Special Needs Plan for people with ESRD, you may be able to get dialysis while you travel. Contact your plan for more information on receiving dialysis treatment while traveling.
In certain situations, Medicare covers ambulance services to and from your home to the nearest dialysis facility for treatment of ESRD if other forms of transportation would be harmful to your health.
If you need ambulance services for non-emergency, scheduled, repetitive transportation, the ambulance supplier must get a written order in advance from your doctor. The written order from your physician must state that ambulance transportation is medically necessary for your condition and cannot be dated any earlier than 60 days before you receive the ambulance service.
If you’re in a Medicare Advantage plan, the plan may cover some non-ambulance transportation to dialysis centers and doctors. Read your plan materials, or call the plan for more information.
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