Does Medicare Cover Dialysis?
This article was updated on: 09/12/2018
If you are enrolled in Original Medicare (Part A and Part B) and have end-stage renal disease (ESRD), Medicare may cover dialysis treatment you get as an inpatient in the hospital. Medicare may also cover routine, outpatient dialysis treatment at a Medicare-certified dialysis facility or self-dialysis training and equipment if you are a candidate for dialysis at home. Here’s how dialysis works and how Medicare may help with costs for treatment.
How does dialysis work?
Dialysis is a treatment for kidney failure. Healthy kidneys act as a filter for the blood, removing waste material, extra salt, and extra fluid that is then excreted in the urine. In people with ESRD, the kidneys are no longer able to effectively filter the blood; the dialysis machine acts as an artificial kidney and replaces the normal function of healthy kidneys. It cannot cure ESRD, but when used with medication and dietary changes, dialysis may make you feel more comfortable and help you live longer.
There are two types of dialysis treatment – hemodialysis and peritoneal dialysis. Hemodialysis hooks up the patient to a machine that filters out waste and fluids through a tube. Peritoneal dialysis cleans your blood and fluids with a special solution called dialysate, which also enters your body through a tube. The dialysate solution needs to be periodically drained from your stomach after it has finished cleaning your blood, then replaced with new solution that continues removing excess waste and fluids.
Talk with your doctor about the best type of dialysis to treat your condition.
Where can you get dialysis?
You may get dialysis during an inpatient stay at a hospital, but most people get ongoing dialysis treatments either at an outpatient dialysis facility or using a self-dialysis machine at home. You and your doctor will work together to choose the right dialysis option for your situation.
At a dialysis center, you typically get treatment on a routine schedule several days a week. A nurse or other technician handles all the tasks associated with your dialysis treatment, including setting up the machine and getting access through a vein.
If you are a candidate for home dialysis, you will still need to choose a dialysis center to train you how to do the procedure at home and care for the equipment, and to do regular follow-up tests and visits with your doctor to make sure the treatment is working properly.
Does Medicare cover dialysis?
If you have end-stage renal disease, you may be eligible for Medicare even if you’re under 65, provided that:
- You need regular dialysis treatments or you’ve had a kidney transplant.
- Your kidneys are no longer functioning.
- You’re currently getting retirement benefits or you’ve worked enough hours under Social Security, the Railroad Retirement Board, or as a federal employee.
You may also qualify if you’re the spouse or dependent child of a person who meets the above criteria. See this article for more information on Medicare eligibility before age 65.
Once you’re enrolled in Original Medicare, Part A covers dialysis treatment you receive as an inpatient in a Medicare-approved hospital. However, for routine, ongoing dialysis treatments, you’ll be covered through Part B, the medical insurance portion. Medicare Part B covers:
- Outpatient dialysis treatments in a Medicare-certified dialysis facility
- Doctor visits, lab tests, and other outpatient care services
- Ambulance transportation to the nearest dialysis facility only if medically necessary and other types of transportation could endanger your health
- Self-dialysis training in a Medicare-certified dialysis facility for you and the person assisting you with treatments. You may be eligible if you think at-home dialysis could be helpful and you receive doctor approval.
- Self-dialysis support services (for example, home visits by trained dialysis staff to monitor your self-dialysis progress and equipment)
- Self-dialysis medical equipment and supplies (such as dialysis machines, alcohol, wipes, etc.)
- Medications for self-dialysis
Your Part B deductible and coinsurance amounts apply for dialysis treatments and equipment.
Part B does not cover:
- A paid medical aide to help you with self-dialysis at home
- Blood or blood products for self-dialysis unless it’s provided as part of a doctor’s service
- Housing during your dialysis treatments
- Income lost on behalf of you or someone assisting you during self-dialysis
- Medications for End Stage Renal Disease that only come in oral form (these are covered through Part D; see below)
- Prescription drugs for other conditions, such as hypertension medications
As mentioned, Medicare Part B covers medications you get in an outpatient dialysis facility and during self-dialysis. However, for coverage of ESRD medications that can only be taken orally, or for most prescription drugs you take yourself at home, you’ll need to enroll in Medicare Part D, the program’s prescription drug benefit. Medicare prescription drug coverage is available through a stand-alone Medicare Prescription Drug Plan that works alongside Original Medicare Part A and B.
In addition, many Medicare Advantage plans also include coverage for prescription drugs. Medicare Advantage plans must cover everything included in Original Medicare (except for hospice care, which is still covered by Part A), but they often have additional benefits, such as routine vision or dental, hearing, or wellness programs. Many have lower deductibles, coinsurance and copayments, to reduce your out-of-pocket costs. However, if you have End Stage Renal Disease eligibility for a Medicare Advantage plan is more complicated, and you are only eligible in certain situations. It may depend on when you were diagnosed with ESRD and whether there is a Medicare Advantage Special Needs Plan in your area (see below for more info).
Can I get dialysis coverage with a Medicare Advantage plan if I have End Stage Renal Disease?
If you have end-stage renal disease, you may only be eligible for a Medicare Advantage plan under certain circumstances. One of those situations is if there’s a Medicare Advantage Special Needs Plan for people with ESRD in your area. A Special Needs Plan is a certain type of Medicare Advantage plan with benefits targeted for those with unique circumstances, including those with Medicaid and Medicare coverage; those who live in an institution, or those with certain health conditions, like ESRD. A Special Needs Plan for people with ESRD may have special coordination benefits or social services to help you better manage your condition.
As mentioned, you may not be eligible for a Medicare Advantage plan if you have ESRD except in certain situations. If you’re not sure whether you’re eligible to enroll in a plan, feel free to contact a licensed insurance agent at Medicare.com for help – see below for instructions on how to do that.
Still have questions about Medicare and dialysis?
If you have questions or concerns regarding dialysis and how Medicare coverage works, I am happy to help you understand your options. Would you like to set up a phone call or have an email sent to you with personalized plan options? You can find the links to do that below. To browse on your own time and at your convenience, click the Compare Plans button to view plan options in your area.
For more information on Medicare coverage of dialysis, see:
Medicare.gov, “Medicare Coverage of Kidney Dialysis & Kidney Transplant Services,” https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf