Does Medicare cover dialysis and kidney transplants?

Medicare and Medicare Supplement insurance provide expansive coverage for dialysis and kidney transplants, two common treatments for End Stage Renal Disease (ESRD).

ESRD is a condition where your kidneys lose most of their function or stop working completely. When functioning properly, kidneys help filter the body’s blood, prevent the buildup of body waste, keep electrolytes stable, and produce hormones.

ESRD is one of the serious conditions that can qualify you for Medicare coverage before you turn 65. In order to receive the full Medicare coverage for ESRD-related treatment such as dialysis and transplants, you must enroll in both Medicare Part A and Part B (Original Medicare).

There are two common treatments for ESRD. Medicare and Medigap provide extensive coverage for both.

Dialysis and kidney transplants for ESRD

The two most common treatment options for ESRD are dialysis and kidney transplants.

Dialysis

Dialysis is a medical treatment that performs some of the functions that would otherwise be performed by healthy kidneys, such as removing waste from the body, keeping a safe chemical level, and helping to control blood pressure. It can be performed in a hospital, in a dialysis unit, or at home, depending on your needs and your doctor’s recommendations.

Dialysis is recommended when you develop end stage kidney failure and your own kidneys cannot function properly, according to the National Kidney Foundation (NKF). It is usually required by the time you lose 85-90% of your kidney function and have a glomerular filtration rate (GFR) of less than 15.

Medicare.gov provides a search tool to find and compare dialysis facilities in your area. There are two types of dialysis: hemodialysis and peritoneal dialysis.

Hemodialysis

Hemodialysis uses an artificial kidney machine (hemodialyzer) to remove waste and extra chemicals and fluid from your blood.

According to the NKF, your doctor will usually perform a minor surgery on your arm or leg to create an access point from your blood vessels to the machine. Your blood then flows through tubes into the machine, where it is cleaned and returned back to your body.

A hemodialysis treatment is usually performed at a medical clinic with the help of patient care technicians and nurses. Each treatment lasts about 4 hours and is performed about 3 times per week, although your individual needs may vary.

Peritoneal dialysis

Peritoneal dialysis cleans your blood while still inside your body. Your doctor will surgically place a catheter into your abdomen to create an access point. During your peritoneal dialysis treatment, your abdomen is slowly filled with a liquid solution (dialysate) through the catheter. The blood stays in your arteries and veins, and the extra fluid and waste are removed from your blood and into the solution.

A peritoneal dialysis treatment is generally performed at your home without the oversight of a medical professional. There are several types of peritoneal dialysis. Your doctor will recommend the best treatment option and frequency according to your needs.

Kidney transplants

A kidney transplant is an operation where a person with a failing kidney receives a new, functioning kidney.

If you receive a kidney transplant, it can come from either a living donor or a deceased donor. Living donors are usually a spouse, family member, or close friend.

Medicare and Medicare Supplement insurance coverage for ESRD treatments

Medicare Part A and Part B provide different dialysis and transplant-related coverage. Medicare Part A provides inpatient hospital care coverage and Medicare Part B provides medical care coverage.

Medicare Supplement insurance coverage will help you pay for some of the out-of-pocket costs associated with that coverage. This may be important to you if you use dialysis, since it will help pay for all of Medicare Part B co-payments that are required for most dialysis-related services.

Dialysis coverage

The chart below shows which dialysis services and supplies are covered by either Medicare Part A or Part B, according to Medicare.gov, and the costs you would face (in addition to Medicare Part A and Part B premiums and deductibles).

Although Medicare provides significant coverage for dialysis and related treatments, there are several things that Medicare does not cover, including:

1. Blood or packed red blood cells for home dialysis, unless part of a doctor’s service;
2. Paid dialysis aides to help with home dialysis;
3. Any lost pay for you or your dialysis caregiver during home training; and
4. A place to stay during dialysis treatment.

Kidney transplant coverage

The chart below shows which kidney transplant services and supplies are covered by either Medicare Part A or Part B, according to Medicare.gov, and the costs you would face (in addition to Medicare Part A and Part B premiums and deductibles).

Kidney Transplant and Medicare Coverage

Medicare Supplement insurance (Medigap) can help reduce your Medicare-related costs for dialysis and a kidney transplant.

Medicare beneficiaries with ESRD face high out-of-pocket costs in comparison to those with other chronic conditions, according to a Kaiser Family Foundation (KFF) report. In 2010, Medicare beneficiaries with ESRD paid an average of $5,110 in out-of-pocket costs for services such as:

• Home health
• Inpatient and outpatient hospital care
• Medical supplies
• Prescription drugs
• Skilled nursing facility care

In comparison, the average beneficiary spent only $2,744 a year on services that year.

A Medigap policy covers some of the out-of-pockets costs left by Medicare such as co-insurance, co-payments, deductibles, and other health care expenses. The coverage amount depends on the Medigap plan you choose. Our Medigap plan options page has more information about the coverage provided by each standardized plan.

If you are under the age of 65 and qualify for Medicare due to ESRD, you may not qualify for a Medigap plan. State laws regulate whether or not an insurance company must offer a Medigap policy to these individuals.

When Medicare coverage begins and ends for under-65 beneficiaries

If you are 65 and above and enrolled in Medicare, your ESRD treatment will be covered immediately as long as it is deemed medically necessary. If you are under 65 and qualify for Medicare due to ESRD, your coverage begins and ends at specific times depending on the treatment you receive.

Medicare coverage begins

If you qualify early for Medicare because of ESRD and are on dialysis, coverage usually begins on the first day of treatment for peritoneal dialysis patients and on the first day of the fourth month of treatment for hemodialysis patients. This is applicable even if you have not signed up for Medicare yet. However, Medicare coverage may start at different times depending on certain conditions.

If you are under age 65 and currently receive health insurance through an employer or union group health plan, your current plan is the primary payer for the first 3 months of dialysis. If your insurance company does not pay for all of the dialysis costs, you may be responsible for the remaining costs.

If you are getting a kidney transplant, Medicare coverage may begin the month you are admitted to a Medicare-approved hospital for a kidney transplant or related service, as long as your transplant takes place within the next 2 months.

Medicare coverage ends

If you are eligible for Medicare coverage early because you have ESRD, Medicare.gov states that your coverage will likely terminate in one of the following situations:

1. 12 months after the month you stop dialysis treatments; or
2. 36 months after the month you have a kidney transplant.

Your Medicare coverage may be extended if you start dialysis again or if you get a kidney transplant within 12 months after the month you end dialysis. Your coverage may also be extended if you start dialysis or get another kidney transplant within 36 months after the month you get a kidney transplant.