When your kidneys stop functioning properly, your body progresses into End-Stage Renal DiseaseEnd-Stage Renal Disease (ESRD), also known as kidney failure, is a condition that causes you to need dialysis or a kidney transplant. People with ESRD are eligible for Medicare coverage regardless of age. (ESRD). In most cases, the treatment is dialysis to artificially clean your blood.
In this MedicareWireMedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. article, we’ll explain how Medicare covers kidney dialysis and other ESRD treatments and who is eligible.
Key Takeaways
- Dialysis is a procedure that filters out waste material from your blood with a dialysis machine when your kidneys are not functioning.
- Medicare and Medicare Advantage will cover dialysis and most treatments that involve ESRD.
- Medicare coverage is available for ESRD patients of all ages, not just people over the age of 65.
- ESRD-based Medicare coverage begins on the first day of your fourth month of dialysis.
- ESRD-based Medicare coverage ends after you have stopped dialysis for 12 months, but it can resume if you need dialysis treatment again.
- Medicare will cover non-emergency ambulance transportation if your doctor considers it necessary for your treatment.
- Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. will cover prescription drugs for ESRD that require a health care providerA person or organization that’s licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers. to administer them, while Part D will cover other prescription drugs.
What Is Dialysis?
Dialysis is a system that manually filters your blood when your kidneys are no longer able to do the job. Dialysis is usually performed with a hemodialysis machine at a dialysis center, which filters the waste in your bloodstream that your kidneys would normally filter out. Some self-dialysis options can be done from home if needed, such as peritoneal dialysis, which uses a medical fluid to flush out the waste from your blood vessels.1Mayoclinic.org, “End-stage renal disease: Diagnosis & treatment“, Accessed November 24, 2021.
While receiving dialysis treatments, you may be required to adhere to a strict dietary regimen to minimize the amount of work and stress your kidneys experience. A dialysis diet plan may include instructions to:1Mayoclinic.org, “End-stage renal disease: Diagnosis & treatment“, Accessed November 24, 2021.
- Eliminate foods with added salt, such as canned goods, fast food, and processed meats and cheeses.
- Avoid high-potassium foods, such as bananas, oranges, potatoes, spinach, and tomatoes.
- Reduce the amount of protein you eat each day.
How Does Medicare Cover Dialysis?
Medicare covers most supplies and services needed for dialysis, including:2Medicare.gov, “Dialysis services & supplies“, Accessed November 24, 2021
- Inpatient dialysis treatments
- Outpatient dialysis treatments
- Outpatient doctor visits
- Home dialysis training
- Home dialysis equipment and supplies
- Certain home support services
- Most drugs for in-facility and at-home dialysis
- Other services and supplies, such as laboratory tests
- Dialysis when you travel in the U.S. and its territories
If you’re under the age of 65 and have End-Stage Renal Disease (ESRD), you may qualify for enrollment in Medicare without meeting the normal age limit. Medicare coverage obtained this way is not limited only to ESRD services and treatments. You can use Medicare for all the services that it normally covers.3Medicare.gov, “I have End-Stage Renal Disease (ESRD)“, Accessed November 24, 2021
When Will My ESRD-Based Medicare Coverage Begin?
If you qualify for Medicare benefits based on ESRD and you’re currently on dialysis, your Medicare coverage typically starts the first day of your fourth month of dialysis treatment. Coverage can begin on the first month of treatment if:3Medicare.gov, “I have End-Stage Renal Disease (ESRD)“, Accessed November 24, 2021
- 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 admitted for a kidney transplant and the transplant takes place within two months, Medicare benefits will begin the month you are admitted. Medicare coverage can begin two months prior to your transplant if the transplant is delayed more than two months.3Medicare.gov, “I have End-Stage Renal Disease (ESRD)“, Accessed November 24, 2021
When Will My ESRD-Based Medicare Coverage End?
If your Medicare eligibility is based on permanent kidney failure only, your coverage will end:3Medicare.gov, “I have End-Stage Renal Disease (ESRD)“, Accessed November 24, 2021
- 12 months after the month your dialysis treatments ended
- 36 months after the month of your kidney transplant
Medicare coverage may resume if:3Medicare.gov, “I have End-Stage Renal Disease (ESRD)“, Accessed November 24, 2021
- Within 12 months of your last dialysis treatment you require dialysis treatment again or have a kidney transplant; or
- Within 36 months after the month you get a kidney transplant you require dialysis or need another kidney transplant.
Transportation To Dialysis Facilities
Medicare generally covers ambulance services, when required, to and from home and the closest dialysis facility. Your doctor may need to provide written orders certifying that it’s a medical necessity for non-emergency situations.4Medicare.gov, “Ambulance services“, Accessed November 24, 2021
Prescription Drug Coverage
Medicare Part B will cover any prescription medication that requires a health care provider to administer it to you. This includes injectables, intravenous (IV), and certain oral drugs that treat or manage conditions associated with ESRD (like anemia) or are used in the treatment of ESRD.2Medicare.gov, “Dialysis services & supplies“, Accessed November 24, 2021
Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... will cover any prescription medications you need for your dialysis treatments that are not covered by Part B. Part D plan members may have to pay an annual deductible before the plan begins paying its share, as well as a co-payment with each prescription.5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 24, 2021
Medicare Advantage Dialysis Coverage
As of January 2021, people with ESRD can join a Medicare Advantage planMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B).. Previously, only Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. was available to people diagnosed with ESRD. Special Needs Plans (SNPs) may be available in some areas to address the specific needs of ESRD patients. SNP-C plans are customized to the particular needs of their covered condition, providing benefits and additional services that go beyond what Medicare usually covers, which can include:3Medicare.gov, “I have End-Stage Renal Disease (ESRD)“, Accessed November 24, 2021
- A care team of specialists for the special condition
- A case coordinator to optimize the coordination of services you need
- Extra hospital days
- Drug coverage formularies tailored to your condition
These benefits may not be available for every Medicare Advantage SNP. Ask your local Medicare Advantage providers about which SNPs they offer and what benefits they provide.3Medicare.gov, “I have End-Stage Renal Disease (ESRD)“, Accessed November 24, 2021
Medicare Supplement Dialysis Coverage
Medicare supplement insurance (MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage.) covers some or all of the out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. associated with Medicare-approved dialysis treatments. These costs include:6Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed November 12, 2021
- DeductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.
- CoinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service.
- CopaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.
- Blood
Medigap policies are not widely available to people under the age of 65, even if you qualify for Medicare benefits due to a disability or (ESRD). It varies from area to area, so you will have to check the Medigap providers in your area for an appropriate Medigap plan.
Summary
Once your kidneys have failed, they cannot be brought back to life. However, dialysis treatments can help you with the strain of ESRD and keep your health from trending down while waiting for kidney transplant services. Thankfully, Medicare does cover dialysis and other ESRD treatments for beneficiaries of any age.
Citations
- 1Mayoclinic.org, “End-stage renal disease: Diagnosis & treatment“, Accessed November 24, 2021
- 2Medicare.gov, “Dialysis services & supplies“, Accessed November 24, 2021
- 3Medicare.gov, “I have End-Stage Renal Disease (ESRD)“, Accessed November 24, 2021
- 4Medicare.gov, “Ambulance services“, Accessed November 24, 2021
- 5Medicare.gov, “What Medicare Part D drug plans cover“, Accessed November 24, 2021
- 6Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed November 12, 2021