Medicare Dialysis Services Coverage

According to the American Kidney Fund, 37 million Americans live with chronic kidney disease. Many people with this condition will go on to have kidney failure, also called end-stage renal disease (ESRD).

Kidney failure does not need to stop you from living life to its fullest. You will, however, require dialysis or a kidney transplant, two life-saving treatments which are prohibitively expensive without health insurance.

Medicare is available for eligible people with ESRD, no matter what their age. In this article we’ll go over the costs and basics of Medicare coverage for kidney failure.

If you have Medicare, the costs you incur for dialysis will be determined by several factors, including where you receive the dialysis treatment.

As an inpatient:

• If you’re admitted to a Medicare-approved hospital and get dialysis as an inpatient, Medicare Part A will cover those costs. Part A will also cover your nephrologist (kidney doctor) fees, and other fees associated with your care.
• Part A is premium-free for people with ESRD, provided you meet Medicare’s work history and eligibility requirements.
• If you have been hospitalized for 61 days or longer, you may have coinsurance fees. You will also be responsible for paying a deductible for each benefit period.

As an outpatient:

• If you receive dialysis at a Medicare-approved facility as an outpatient, Medicare Part B will cover 80 percent of the Medicare-approved cost, including doctor’s fees.
• You will be responsible for the other 20 percent of the cost of dialysis. You are also responsible for the Part B annual deductible and typically must provide your own travel to and from the facility.
• Medicare Part B covers 80 percent of the cost of at-home dialysis, plus dialysis training for you and another person.

If you have a Medigap supplemental insurance plan, some or all of the costs that remain after Medicare pays for dialysis may be covered by your plan.

If you have a Medicare Advantage (Part C) plan, your plan will cover at least as much as Original Medicare does. However, your costs for dialysis, both in and out of the hospital, may be different.

Is there a copay for dialysis?

No. That doesn’t mean you are not responsible for a portion of the payment for dialysis. Some people confuse copays with coinsurance. A copay is a set rate that you pay out of pocket for items such as doctor’s appointments. Coinsurance refers to the percentage of the cost that you are responsible for paying after you have met your plan’s deductible.

There is no set copay for dialysis. There is, however, a 20% coinsurance fee for dialysis you receive as an outpatient in a Medicare-approved dialysis facility.

If you’re on dialysis and under 65, you can still get Medicare. This is sometimes referred to as ESRD Medicare.

With Medicare, you’ll have coverage for dialysis, no matter your age. To get coverage, you must also meet one these requirements:

• You’ve worked for at least the required amount of time needed under Social Security, the Railroad Retirement Board, or as a governmental employee
• You’re getting or are eligible to get Social Security or Railroad Retirement benefits
• You are the child or spouse of an individual who meets one of the requirements listed above

Your Medicare coverage will most likely start on the first day of the fourth month of your dialysis treatments.

Keep in mind that getting Medicare is not automatic. You will need to sign up for both Medicare Part A and Medicare Part B.

Some of your medications will be covered by Original Medicare. To get full prescription drug coverage you also need to sign up for Medicare Part D, or a Medicare Advantage (Part C) plan that contains prescription drug coverage.

People under 65 with Medicare have coverage for:

• In-hospital dialysis
• Outpatient dialysis
• Kidney transplants
• Immunosuppressant drugs

There is no cap on the length of time that Medicare will pay for dialysis. If you continue to need it, Medicare will continue to pay for it.

However, if you’re under 65 and have ESRD Medicare, you will lose your benefits and Medicare will stop paying for dialysis and all other medical treatments if:

• It is 12 months after the month you stop dialysis treatment, or
• It is 36 months after the month you had a kidney transplant

You can, however, resume receiving Medicare and coverage for dialysis if:

• You start dialysis again, or have a kidney transplant within 12 months after the month you stop getting dialysis, or
• You get a second kidney transplant or start dialysis within 36 months after the month you got your first kidney transplant

There may be a waiting period or lag time before your coverage resumes.

Medicare Part B pays 80 percent of the Medicare-approved costs associated with home dialysis. You are responsible for the other 20 percent.

Coverage for home dialysis includes:

• Training for you and another person to administer dialysis within a home setting
• Home dialysis equipment and supplies
• Laboratory tests
• Dialysis medications

End stage renal disease is covered by Medicare. If you receive treatments in a Medicare-approved hospital as an inpatient, Part A will cover it.

If you receive treatments as an outpatient, Medicare Part B will cover 80 percent of the Medicare-approved costs for your care.

If you have health insurance when you become eligible for ESRD Medicare, you don’t have to enroll immediately. If you decide to keep your current insurance, it will remain your primary insurance for 30 months, starting with the first month you are eligible for Medicare. This is known as the 30-month coordination period.

Your primary insurance will pay for all of your healthcare needs first, and Medicare will pay second during the 30-month coordination period. Once this period ends, Medicare will automatically become your primary payor.

This 30-month period begins whenever your eligibility for Medicare begins, even if you haven’t as yet signed up for it.

During the 30-month coordination period, you can sign up at any time for Part A and Part B. However, you must sign up for both at the same time. If you choose to enroll in Part A but not Part B, you will be unable to enroll in Part B later in the 30-month period. In this instance, you will have to wait until the next Medicare General Enrollment Period, and may incur penalties when you sign up.

People with kidney failure may enroll, disenroll, and re-enroll in Medicare multiple times. Each time you enroll in ESRD Medicare you will have a new 30-month coordination period.