Original Medicare covers care and supplies for end stage renal disease (ESRD). This includes inpatient and outpatient dialysis, home dialysis training, and equipment.
Medicare Advantage (Part C) is an alternative to Original Medicare and offers the same level of coverage. Advantage plans also cover dialysis, but many people will not qualify for it. Yet, exceptions to this rule may exist.
This article explores Original Medicare and Medicare Advantage coverage of dialysis, eligibility, and costs.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
For people already enrolled in Medicare, Original Medicare (parts A and B) provides coverage for dialysis, including:
- 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 also 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
ESRD-based enrollment
If a person enrolls in Medicare because they have ESRD, their dialysis coverage starts on the first day of the fourth month of treatment in a clinic.
However, under two conditions, coverage may start the same month that they begin treatment instead:
- A person participates in a home dialysis training program before the third month 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:
Learn more about Medicare and ESRD coverage.
If a person enrolls in a Medicare Advantage (Part C) plan, they can expect all or most of the coverage of Original Medicare (parts A and B).
These plans often include Part D prescription drug coverage as well. They may also provide extra benefits, such as transportation to a dialysis facility.
Yet, while Original Medicare offers coverage of services from any Medicare-approved professional or facility, Advantage plans may only offer coverage from in-network providers.
Not all Advantage plans pay for dialysis when an individual travels in the United States, but some do. People should check their coverage with their plan provider.
The information below offers details on eligibility for Original Medicare and Medicare Advantage plans.
Original Medicare
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 Administration (SSA) or as a government employee.
- They are eligible for RRB or SSA benefits.
- They are the dependent child or spouse of an individual who meets either of the above two criteria.
Medicare Advantage
All people with ESRD who are 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, which came into effect in 2021.
Prior to this change, a person with ESRD could join a Medicare Advantage plan only under these circumstances:
- They were enrolled in an Advantage plan at the time they developed ESRD. In this case, an individual could keep their plan or join another plan that the same company offers.
- They had health insurance via an employer’s health plan through the same company that offered an Advantage plan.
- They had joined a type of Advantage plan called a Special Needs Plan (SNP), if available in their area.
Previously, an individual was able to change Medicare Advantage plans only one time and only if they met certain conditions.
Since the change, though, people can now change their enrollment during the open enrollment period (OEP). They may pick another Medicare Advantage plan or switch back to Original Medicare.
The Medicare Advantage OEP is from January 1 to March 31.
The information below explains the dialysis costs involved in Original Medicare and Medicare Advantage.
Original Medicare
Most people with original Medicare who have ESRD do not have to pay a monthly premium for Part A, which is hospitalization insurance.
They do need to pay the premium for Part B, medical insurance. This is $174.70 per month in 2024. Other costs include the Part B yearly deductible of $240 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. However, it does not pay for drugs that are available in oral form only.
If someone needs these medications, they may consider buying a Medicare Part D plan, which offers prescription medication coverage.
Medicare Advantage
Costs for Medicare Advantage vary depending on the specific 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 the additional premium.
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.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Original Medicare (parts A and B) 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, also called Medigap.
Medicare Advantage (Part C) 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 suits their needs.