Original Medicare covers care and supplies needed for ESRD. This includes inpatient and outpatient dialysis, home dialysis training, equipment, and supplies.
Medicare Advantage, or Part C, is the alternative to original Medicare. This plan also covers dialysis, but many people will not qualify for this option. However, there may be exceptions to this rule.
This article explores original Medicare and Medicare Advantage coverage of dialysis, eligibility, and costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
- inpatient dialysis for a person admitted to a hospital
- outpatient dialysis and related doctor services
- most drugs appropriate for dialysis
- home dialysis equipment and supplies
- services related to dialysis, such as laboratory tests
- dialysis services when traveling in the United States
Original Medicare covers home dialysis equipment, including a dialysis machine and items such as sterile drapes, rubber gloves, and alcohol.
Medicare coverage does not include:
- compensation for any lost pay for the person who is ill or their caregiver
- dialysis aids to help with home treatment
- a place to stay while undergoing dialysis
- blood for home dialysis unless a doctor performs the procedure
However, coverage starts the first month of treatment under two conditions:
- A person participates in a home dialysis training program during the initial 3 months of treatment.
- An individual’s doctor expects them to complete home dialysis training and do their own dialysis at home.
The chart below shows an example of when a person’s Medicare coverage would start if their ESRD dialysis treatment started in March.
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If a person enrolls in a Medicare Advantage plan, they can expect all or most of the coverage of original Medicare. These plans often include Part D prescription drug coverage and may provide extra benefits, such as transportation to a dialysis facility.
However, while original Medicare offers coverage of services from any Medicare-approved provider, Advantage plans may only offer coverage from in-network providers.
Not all Advantage plans pay for dialysis when an individual travels in the U.S., but some do, so people should check their coverage with their plan provider.
The information below offers details on eligibility for original Medicare and Advantage plans.
Regardless of a person’s age, if they have ESRD, they are eligible for original Medicare if they meet one of these requirements:
- They have worked the required amount of time under the Railroad Retirement Board (RRB) or Social Security or as a government employee.
- They are eligible for RRB or Social Security benefits.
- They are the dependent child or spouse of an individual who meets either of the above two criteria.
As of January 2021, all people with ESRD eligible for Medicare can enroll in Medicare Advantage even with an existing diagnosis. This change is a result of an amendment to the 21st Century Cures Act.
Prior to this change, a person with ESRD had been able to join a Medicare Advantage plan only under these circumstances:
- They have enrollment in an Advantage plan at the time they develop ESRD. An individual may keep their plan or join another plan that the same company offers.
- They have health insurance via an employer’s health plan through the same company that offers an Advantage plan.
- They have joined a type of Advantage plan called a Special Needs Plan (SNP) if one is available in their area.
Previously, an individual had only been able to change Medicare Advantage plans one time, and only if they met certain conditions. Since the change, people can now change their enrollment during the open enrollment period. They may pick another Medicare Advantage plan or switch to original Medicare.
The information below explains the dialysis costs involved in original Medicare and Medicare Advantage.
Most people with original Medicare who have ESRD do not have to pay a monthly premium for Part A, hospitalization insurance.
They do need to pay the premium for Part B, medical insurance, which is $148.50 per month. Other costs include the Part B yearly deductible of $203 and a 20% copay of covered services.
If a person wants additional coverage, they may buy one of the Medicare supplement plans called Medigap. Some Medigap plans pay the deductible, and the plans pay part or all of the copay.
Original Medicare pays for injectable drugs and the oral forms that people need for dialysis. It does not pay for drugs that are only available in oral form. If someone needs these medications, they may consider buying a Medicare Part D plan, which offers prescription medication coverage.
Costs for Medicare Advantage vary with the plan. Some plans cover all or part of the Medicare Part B premium. If a person’s plan does not cover the amount, the individual must pay it themselves.
Another cost of Medicare Advantage is the monthly plan premium, which varies widely among plans and the companies administering them. Other expenses include copays and coinsurance, which also vary by plan.
Advantage plans also have a yearly cap — once a person’s healthcare costs go beyond this limit, they pay nothing.
Original Medicare covers dialysis for people with ESRD. However, a person is responsible for paying Part B’s monthly premiums, deductibles, and copays. To help pay these costs, an individual may wish to buy a Medicare supplement plan.
Medicare Advantage also covers dialysis. The monthly premiums, deductibles, and copays differ from those of original Medicare. They also vary among the plans and the companies that offer them.
Most people with ESRD receive their dialysis coverage under original Medicare. With recent changes, they can now also receive coverage through a Medicare Advantage plan.
A person can compare the coverage of different Advantage plans with the coverage of original Medicare to help them decide which choice best suits their needs.
A note on insurance
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