Does Medicare Cover Dialysis?

Medicare will cover 80% in an approved dialysis center, but you will typically have to pay 20% of the Medicare-approved price for all dialysis services and supplies. You may also have to meet your annual deductible before Medicare pays.

If you have a Medicare Advantage plan or a Medigap plan that covers your coinsurance, it may cover part of your 20% share.

The specific amount you owe will depend on the type of coverage you have and any additional insurance that may cover part of your costs. If you qualify, your state’s Medicaid programs may also help you with costs.

Your doctor will help you decide the best place for your dialysis treatments. It can be done in a hospital, an off-site dialysis center or in your home.

The decision will depend on your medical condition and your wishes. You should also consider what Medicare or other insurance will cover.

There are two types of dialysis: Hemodialysis and peritoneal dialysis.

In hemodialysis, a doctor performs minor surgery to create an access point on your arm and leg. This is done by altering blood vessels or implanting a catheter. This allows your blood to flow through an artificial kidney outside your body when you receive your regular dialysis treatments.

In peritoneal dialysis, your blood is cleaned inside your body by exchanging fluids through a bag or through a machine. Again, a doctor will have to make an access point using a catheter.

Medicare Part B (medical insurance) will cover dialysis services and supplies if they are medically necessary or if you have end-stage renal disease. You must be enrolled in Medicare Part B and paying the monthly premium to qualify.

Medicare typically does not cover transportation to a dialysis facility. The only caveat to this rule would be if you qualified for ambulance services and were transported to a facility in an ambulance.

Ambulance services are covered when you need to get to a hospital or other facility and transportation in a normal vehicle could be life threatening. Some Medicare Advantage plans offer expanded coverage for transportation to facilities.

Medicare should continue to cover your dialysis treatments as they are needed. But if there is a change in your situation, then the length of coverage depends on your eligibility.

For example, if you are only eligible for Medicare because you have end-stage renal disease, then your coverage will expire 12 months after the month you stop receiving dialysis treatments. If you received a kidney transplant, then your coverage will end 36 months after the month of your transplant.

If you were receiving dialysis treatment but had Medicare through the typical eligibility requirements of being 65, then there should be no change to your coverage regardless of your health situation.

Original Medicare covers dialysis treatments. This applies either if you meet regular eligibility requirements or if you don’t but have end-stage renal disease.

Original Medicare is provided through the federal government and comes with a monthly premium for Part B, which covers dialysis.

Another potential option is Medigap, which can help cover some of the out-of-pocket costs from Original Medicare. Dialysis can be very costly, meaning that you can be left with major expenses even after Medicare covers 80% of the cost.

One thing to note is that there are insurance companies that will not sell Medigap to beneficiaries who don’t have Medicare through the typical set of requirements. So, beneficiaries who need dialysis but got Medicare before they turned 65 may not be eligible for a plan.

Medicare Advantage plans may not be the best option to receive dialysis coverage if you already have end-stage renal disease. Generally, you cannot enroll in a Medicare Advantage plan (Part C) if you have already been diagnosed. But there are two prominent exceptions.

However, if you enrolled in a Medicare Advantage plan before you developed ESRD, you cannot be kicked off the plan. And if the plan leaves Medicare or leaves your service area, you will have a special enrollment period to sign up for another Medicare Advantage plan where you live.

Original Medicare — Parts A and B — cover some of the costs for kidney transplants. Your costs may differ if you are enrolled in a Medicare Advantage plan.

Generally, you’ll have to pay the regular out-of-pocket Medicare costs associated with Medicare Part A and Part B. This includes coinsurance or copayments and deductibles.

Under Medicare Part B, that means you’ll have to pay your deductible and 20% of the Medicare-approved amount. Medicare will pick up the other 80%.

Your doctor is limited in how much they can charge if they don’t accept Medicare. If your doctor does not take assignment, you are limited to paying 15% above the Medicare-approved cost for your services.

Medicare will pay for laboratory tests and will help you pay for blood services necessary for your transplant. You will be responsible for paying for the first three units of blood.

Your deductible and a copayment will apply to the rest. You can replace the blood with blood donations, either your own or from people you know or are related to.