Medicare can provide some coverage on dialysis treatment that is medically necessary. Americans nationwide suffering from End-Stage Renal Disease (ESRD) may receive Medicare upon diagnosis.
The body enters ESRD when the kidneys are unable to function on their own. These individuals often require treatment to help the body function properly.
Several signs and symptoms determine these treatment plans. The kidneys act as the filtration system.
Once the kidneys start to fail, the body no longer filters out the toxins and waste within the body. Next, patients become septic which causes illness.
Healthcare providers generally measure a person’s creatinine level and blood urea nitrogen level to determine the treatment plan.
Does Medicare Cover Dialysis
Medicare covers most treatments that involve ESRD or kidney failure, including Dialysis. Original Medicare covers 80% of the costs they approve.
To find a dialysis facility near your service area, use the search tool on Medicare.gov. Medicare coverage for dialysis is available.
Qualifying for Medicare under 65 with ESRD means you must have regular dialysis treatments, a kidney transplant, or kidney failure. However, other opportunities can qualify an individual for Medicare.
Dialysis is a treatment to help the body function when kidneys no longer function on their own. When kidneys no longer hold the ability to function innately, your body enters into End-Stage Renal Disease (ESRD).
There are several signs to determine when you should start receiving treatment. When kidneys begin to fail, waste increases, causing you to become ill.
Once testing is complete, the healthcare provider will recommend a treatment plan.
Types of Dialysis treatments
Making the decision to undergo treatment is the first big step in the right direction. Treatment can seem scary at times, and many uncertainties may arise.
However, the process is surprisingly simple. For starters, there are two types of dialysis treatments: hemodialysis and peritoneal dialysis.
Medicare coverage for hemodialysis dialysis is available. During hemodialysis treatment, blood first passes from the patient’s body. Then, through a dialysis machine where the blood goes through a filter; then back into the patient’s body.
Hemodialysis catheters go into a large vein (in the neck or leg) to carry out the treatment. Treatment in a hemodialysis building includes several dialysis machines.
Patients seeking additional help may also find dietary counseling. Treatments are generally multiple times per week with alternating days.
Each treatment may last several hours, time depends on the patient’s body and the severity of the condition. In some cases, self-dialysis (performing treatments at home) may be an option.
Medicare coverage for Peritoneal Dialysis is available. Treatment for peritoneal dialysis is different. A plastic tube goes into the abdominal region; a special fluid (dialysate) then goes through to flush out waste from the body.
As dialysate goes into the stomach cavity, the intestines become clean. The patient’s body tissue acts as the filter for the fluids with this treatment.
Treatments may be necessary several times per week by administering multiple times each day. This at-home treatment can be easier, given the reduction of travel for care.
However, those who choose this option may have a higher risk of infection.
The Center for Medicare & Medicare Services will pay up to 15 training sessions for peritoneal dialysis and 25 sessions for hemodialysis.
Medicare Coverage for Dialysis for Inpatient, Outpatient, and Home Dialysis
Usually, the facility doing the treatment can give you an idea about the cost of dialysis. Part A covers inpatient kidney dialysis and transplant costs. Part B pays for the surgeons and other medical physicians’ fees for service.
Beneficiaries must pay the 20% coinsurance amount. However, Medicare pays for your kidney donor’s hospital stay expenses; with no extra charge to you.
The second plan includes coverage for receiving routine maintenance dialysis and treatments under Part B. Patients must receive care from a Medicare dialysis facility.
Like inpatient dialysis, beneficiaries pay the 20% coinsurance. Certain doctor fees may also be billed separately, the patient is responsible to cover the costs.
Lastly is the self-dialysis treatment plan. Requiring the patient pays a 20% coinsurance amount. Certified training from a doctor is under Part B coverage.
Training includes showing the patient how to perform and administer treatments on themselves (without assistance). After certification, the patient may carry out treatments in the comfort of their own home.
Dialysis has coverage under Medicare Part A if the patient receives care in a Medicare hospital.
Medicare Part B pays for a variety of services for patients receiving routine dialysis in a Medicare-certified dialysis facility. Part B covers lab tests relating to ESRD and drugs given by a healthcare professional.
However, oral drugs for maintaining ESRD fall under the Medicare Part D prescription drug plan.
Candidates for self-dialysis may find coverage under Part B benefits. Training must be during the patient’s regular treatment schedule. Part B may also pay for the person assisting with self-dialysis treatments.
Facilities often provide support services for self-dialysis patients. Part B may cover visits by a trained hospital or dialysis center worker to ensure self-dialysis is progressing.
Benefits may also include assistance in emergencies and to check your equipment and water supply is adequate.
All dialysis equipment and supplies necessary during self-dialysis have coverage under Part B. Coverage lasts as long as the patient needs the treatment.
Supplies and equipment may include alcohol, sterile wipes, dialysis machines, sterile drapes, rubber medical gloves, and scissors.
Certain drugs for self-dialysis
Part B coverage includes the drug heparin, the antidote for heparin (if medically necessary), topical anesthetics and erythropoiesis-stimulating agents (ESAs) may be a requirement for treating anemia relating to renal disease.
Specifically, Part B covers ESAs such as epoetin alfa or darbepoetin alfa.
Other dialysis services & supplies
All other services like lab tests (and supplies) that are part of treatment are under Part B coverage.
Ambulance transportation coverage may be available for ESRD patients that need dialysis and need help getting to or from a treatment facility. However, beneficiaries should confirm this with their plan as this may vary per case.
Does Medicare Cover Dialysis for Acute Renal Failure
Yes, Medicare will also cover 80% of your medical costs associated with acute renal failure. Unless the beneficiary has a Medigap plan, they’ll be responsible for the remaining 20%.
Costs for Dialysis Treatments with Medicare
Beneficiaries receiving inpatient treatments must pay their Part B yearly deductible before Medicare will pay their portion of the costs.
After the deductible, Medicare covers 80% of the monthly amount. The remaining 20% coinsurance amount is the beneficiary’s responsibility. Although, some cases require treatments for less than one month. In this case, doctors receive pay per day rather than the monthly amount.
Outpatient maintenance treatments incorporate the cost of most dialysis drugs. Patient responsibility is 20% of the amount for each session (at home or in a facility). The Part B deductible applies, and coverage includes the cost of training, support services, equipment, and supplies.
Outpatient treatments include the of self-dialysis drugs, beneficiaries pay 20% of the cost. However, Part D covers the drugs relating to ESRD that only come in oral form.
Does Medicare Advantage Pay for Dialysis?
Yes, however, different costs and restrictions may apply. Medicare Advantage Plans are not allowed to charge any more than Original Medicare would for outpatient dialysis. This rule also applies to immunosuppressant drugs.
Do Medicare Supplement Plans Cover dialysis?
Yes, Medicare Supplement plans will cover the remaining out of pocket costs leftover from treatments. Depending on what letter plan you enrolled in, the Part B deductible may or may not need to be met first.
Medigap Coverage & Out-of-Pocket Costs for Dialysis Treatments
Medigap benefits often include coverage for some or all, of the out-of-pocket expenses that Original Medicare doesn’t pay for. However, beneficiaries under the age of 65 with disabilities or ESRD may not access Medigap insurance policies.
Treatments for some patients may be necessary several times per week. Those without supplement insurance must pay co-insurance, co-pays, and deductibles. These out of pocket expenses can cause a serious financial burden over time.
Currently, only 28 states across the country offer Medicare Supplement coverage for dialysis. Medigap benefits depend on the letter plan and the availability within the state of residency.
All 10 Medigap plans must provide a minimum amount of coverage for the following; Part A coinsurance and hospital costs, Part B coinsurance or copays, the first 3 pints of blood, and Part A hospice care coinsurance or copayment costs.
We encourage you, to call us today if the age of Medicare is nearby. One of our brokers would be glad to discuss your options.
To review your coverage options, contact us; we can help get you the right coverage for all your healthcare needs.