Dialysis and Medicare Plans

While Medicare typically provides health insurance for people age 65 and older or for individuals with some disabilities, it also ensures that people with End-Stage Renal Disease (also called permanent kidney failure) receive the healthcare services they need. If you have kidney failure that requires dialysis or a transplant, you are eligible for Medicare coverage.

Medicare enrollment and coverage for recipients with End-Stage Renal Disease (ESRD) or who require dialysis or a kidney transplant is somewhat different than for recipients who are not battling those conditions. Because of the special health needs you may have, Medicare is slightly more restrictive — the biggest difference being that you cannot enroll in a Medicare Advantage Plan if you are not already in one. But, there are special Medicare rules and scenarios that apply when you receive any kind of benefits because of your kidney condition.

Who Qualifies For Medicare ESRD Coverage

While almost anyone who has renal failure qualifies for Medicare health benefits, there are some limitations. To determine if you are eligible for Medicare coverage to help with the costs of treatment, you must have done one of the following:

• Worked the minimum amount of time required by Social Security — 40 quarters or 10 years with taxable income that paid into Social Security.
• Worked the required minimum amount of time determined by the Railroad Retirement Board
• Worked the required minimum time as a government employee
• Already receive Social Security or Railroad Retirement Board benefits, or be eligible to receive them
• Be the spouse or child of a person who has met one of the above work requirements

Unlike many beneficiaries who are automatically enrolled in Medicare after filing for disability benefits or reaching a certain age, you will be required to file an application to receive your benefits. In some cases, applicants do not qualify for Medicare coverage; if this is your situation, you can apply for financial assistance from your state.

Medicare Coverage Plans For People With Kidney Failure

If you enroll in Medicare because you have renal failure, the only coverage option you will have is Original Medicare. With this coverage, you will be able to receive the care you need at doctor’s offices and hospitals, as well as prescription medications, but you will not have coverage for additional benefits that many Medicare Advantage plans offer, such as hearing aids, glasses or dentures.

If you are already enrolled in a Medicare Advantage plan when you are diagnosed with kidney failure, you can keep your plan and will not have to switch to Original Medicare. The plan must offer you the same kinds of health benefits that Original Medicare would, and you may see changes or limitations on the doctors and clinics you can visit.

How Medicare Works With Dialysis Treatments

Medicare will help cover the cost of your dialysis treatments, but there are differences in which part of Original Medicare kicks in based on how you receive your treatment. In general, Medicare covers these dialysis services and supplies:

• Inpatient dialysis at a hospital
• Outpatient dialysis at a Medicare-approved facility
• Outpatient doctors’ services
• Home dialysis training for you and anyone who will help with your at-home treatments
• Home dialysis equipment and supplies
• Some home support services such as visits from dialysis facility workers who can occasionally check in, visit in an emergency and examine your home dialysis equipment
• Many of the prescription medications you might need for dialysis (both at home and in a dialysis facility)
• Related testing, services and supplies that are necessary for dialysis treatment

Medicare Part A (hospital insurance) will cover any inpatient dialysis that you receive at a hospital or medical facility where you have been admitted. For the remainder of your dialysis services, Medicare Part B (medical insurance) will kick in to cover much of your expenses. Unfortunately, there are some dialysis services and supplies that Medicare will not pay for, including:

• Payment for dialysis aids who assist with home dialysis
• Hotel accommodations where you might stay during treatment
• Wages you or a caretaker lost during home dialysis training
• Blood or packed red blood cells that you may need for home dialysis, except in cases where these are provided by a doctor

Home Dialysis and Dialysis Facilities

You may have the choice to receive dialysis treatments at a facility or at your own home (with training). Medicare will provide coverage for some of your dialysis needs regardless of which method you choose.

If you decide to receive treatment at a dialysis center, Medicare Part B will pay for your health care only if the facility is specifically Medicare-certified for dialysis. Some health care centers have Medicare coverage for other services but not dialysis, so it’s vital that you confirm your selected dialysis center has this level of certification. Original Medicare will also cover ambulance transportation services between your home and the dialysis center if any other way of traveling there would endanger your health, as determined by a doctor. (Medicare Advantage plans may or may not offer ambulance transportation.) In this case, a doctor’s written order must state that traveling by ambulance is medically necessary to ensure your safety.

Medicare Part B also covers home dialysis. If a doctor approves you for home dialysis treatments, you will be required to attend dialysis training sessions. These take place at the same time you receive your treatment to teach you and a caretaker the dialysis process, and the cost of training will be covered by Medicare. After you begin home dialysis, Medicare will pay for monthly doctor’s visits to ensure your treatment is effective (it’s possible to also get coverage for visits from some physician assistants and nurses). Your dialysis supplies will be provided by the dialysis center that trained you, and Medicare will cover much of the cost of these items.

Coverage for Dialysis-Related Medications

Original Medicare Parts A and B provide coverage for services at hospitals, doctors’ offices and Medicare-certified dialysis centers. Neither portion covers medications, which are a large component of dialysis treatment. If your treatment requires prescription drugs, you enroll in Medicare Part D to ensure you can access the medications you need. Medicare Part D is provided through private insurance companies and you will be able to select a plan that best fits your needs and budget. For dialysis patients with a Medicare Advantage plan, you may already have prescription drug coverage, though it is a good idea to review your coverage to ensure you get the medications. PolicyZip’s Medicare Specialists can help you compare your drug plan options to find the optimal level of benefits at the most cost effective price.