Original Medicare parts A and B cover kidney dialysis for people who have end stage renal disease.
The coverage includes inpatient and outpatient dialysis, along with home dialysis training, equipment, and supplies.
Medicare Advantage, the alternative to original Medicare, also covers dialysis, but most people are not eligible for this program. However, there are exceptions to this rule.
This article examines coverage of dialysis by original Medicare and Medicare Advantage, as well as eligibility and costs.
We also describe end stage renal disease (ESRD) and explains dialysis treatment.
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.
The information below provides details on the dialysis coverage of original Medicare and Medicare Advantage.
- 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
The home dialysis equipment and supplies that original Medicare covers include the dialysis machine, recliner, and items such as sterile drapes, rubber gloves, and alcohol.
Once someone enrolls in Medicare due to ESRD, coverage of dialysis starts the first day of the fourth month of treatment in a clinic.
However, coverage starts the first month of treatment under these 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 dialysis treatment started in March.
|First month of|
|Second month of|
|Third month of|
|Fourth month of|
Medicare coverage does not include:
- transportation to a dialysis facility
- dialysis aids to help with home treatment
- a place to stay while undergoing dialysis
If a person is eligible for an Advantage plan, they can expect all or most of the coverage of original Medicare, as well as the prescription drug coverage of Part D.
Not all plans pay for dialysis when traveling in the United States, but some do.
In addition, some Advantage plans provide extra benefits, such as transportation to a dialysis facility.
While original Medicare offers coverage of services from any Medicare approved provider, Advantage plans may only offer coverage from in-network providers.
The information below provides details on eligibility for Original Medicare and Medicare Advantage.
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 one of the above two criteria.
A person with ESRD may join a Medicare Advantage plan under these circumstances:
- They are enrolled 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 join a type of Advantage plan called a Special Needs Plan if one is available in their area.
An individual may change Medicare Advantage plans only one time, and if they meet one of the following conditions:
- They have ESRD and are enrolled in an Advantage plan.
- Their Advantage plan is no longer available in their area.
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 $144.60 per month.
If a person wants additional coverage, they may buy one of the Medicare supplement plans called Medigap. Some Medigap plans pay the deductible, and all of the plans pay part or all of the copay.
Original Medicare pays for injectable drugs and their oral forms that people need for dialysis.
It does not pay for drugs that are only available in oral form, so someone needing such medications 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 any of it, they must pay the monthly $144.60.
Another cost of Medicare Advantage is the monthly premium of a person’s plan. This premium varies widely among plans and the companies that offer them.
Other expenses include copays and coinsurance, which also differ with the plan.
Advantage plans have a yearly cap. Once a person’s healthcare costs go beyond the cap, they pay nothing.
Kidneys remove wastes and extra water from the body.
When the kidneys undergo damage that results in a loss of 85–90% of their function, a doctor diagnoses a person’s condition as kidney failure, or ESRD, according to the National Kidney Foundation.
When a person’s kidneys fail, they experience symptoms, including weakness, nausea, and weight loss. Although no cure exists for ESRD, treatment can enable a person to live a long life.
The main two treatments for ESRD are dialysis and a kidney transplant. According to the Centers for Disease Control and Prevention (CDC), nearly
Dialysis performs the kidney functions of getting rid of wastes and fluids that build up in the body.
There are two types of dialysis:
- Hemodialysis cleans the blood through a special filter connected to a machine. During treatment, a person’s blood flows through tubes that remove wastes. After cleansing, the blood flows through another set of tubes back into the body.
- Peritoneal dialysis cleans the blood through use of a special solution that flows from a tube into an individual’s abdomen. Once the solution removes the wastes, it drains out of the body through the tube.
Original Medicare covers dialysis for people with ESRD. However, they are responsible for paying Part B monthly premiums, deductibles, and copays. To help pay these costs, a person 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, but under a few circumstances, they can choose an Advantage plan.
Someone who is eligible can compare the coverage of different Advantage plans with the coverage of original Medicare to help them decide which choice best suits their needs.