Medicare Coverage for Kidney Disease

Kidney Failure, Dialysis, Transplants, and More

Hemodialysis machine in the ward
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The kidneys are paired organs that lie in the back side of the abdomen on either side of the spine. They are responsible for filtering blood, balancing electrolytes (e.g., sodium, potassium), and removing excess fluid and waste from the body. Without at least one functioning kidney, you could not live.

There may be times when your kidneys struggle to work at their best. These impairments may be the result of dehydration, exposures to chemicals, infection, or any number of stressors.

In most cases, the kidneys will recover if the underlying problem is corrected.

In other cases, you could be stuck with long-term kidney disease. In fact, the National Institute of Diabetes and Digestive and Kidney Diseases reports that 14 percent of Americans have some type of chronic kidney disease, staged I through V. If that chronic kidney disease gets bad enough (stage V), you will be diagnosed with end-stage renal disease (ESRD), meaning your kidneys are failing. Without dialysis or an organ transplant, your life is at risk.

Approximately 660,000 people in the United States suffer from ESRD with more than 468,000 on dialysis and about 190,00 living with functioning kidney transplants. Over 93,000 Americans are currently waiting for a kidney transplant.

Eligibility and Enrollment in Medicare

Having end-stage renal disease could qualify you for Medicare. This is the case even if you are not yet 65 years old.

Don't assume the government is being generous. There are other criteria that must also be met:

  • You must satisfy eligibility requirements for either Social Security Disability Insurance or Railroad Retirement Board benefits.
  • You, your spouse, or your guardian (if you are a dependent) has to have already paid at least 40 quarters (10 years) of payroll taxes into Medicare and Social Security.

    Unlike people with other types of disabilities, you do not have to wait 24 months before you become eligible for the program. The same goes for people with amyotrophic lateral sclerosis (ALS). As soon as the criteria above are met, you should apply for Medicare. Your coverage benefits will kick in three months after you start dialysis treatment.

    When You Are on Dialysis

    Dialysis is not one size fits all. Believe it or not, you have options. You could receive hemodialysis (dialysis using a man-made filter) or peritoneal dialysis (dialysis using the peritoneal membrane in your abdomen as a filter). You could receive dialysis as an inpatient, as an outpatient, or at home. Medicare provides coverage for each of these treatment options but how it pays for each service differs:

    • Inpatient Dialysis: Inpatient dialysis means you are admitted to the hospital to receive treatment. This may be the case the first time you undergo dialysis or if dialysis is needed on an emergent basis. As an inpatient, your care will be billed to Medicare Part A. This makes you responsible for a deductible of $1,316 for each hospital stay. Any physician care you receive in the hospital will be billed to Medicare Part B, requiring you to pay a 20 percent coinsurance for those services.
    • Outpatient Dialysis: Outpatient dialysis may be performed at a certified dialysis clinic or even at a Medicare-approved hospital. The difference is that you are not admitted to the hospital as an inpatient. Outpatient services are billed under Medicare Part B. This means you will pay a 20 percent coinsurance for each dialysis session. This will include laboratory tests, medications, and physician care used for your dialysis treatment.
    • Home Dialysis: Getting dialysis at home (or anywhere that is convenient for you) may be the most appealing option schedule-wise, but it does come with risks. Medicare Part B pays for home dialysis training from a dialysis facility, training for you and caregivers who will provide home dialysis, and for home dialysis equipment, supplies, and medications. You will also be required to see a supervising physician at least once per month. Again, you are left to pay a 20 percent coinsurance.

      You will want to consider how much a specific treatment will cost you out of pocket before you commit to one type of dialysis over another.

      When You Get a Kidney Transplant

      Similar to inpatient dialysis, Medicare Part A will cover you to receive a kidney transplant. This will require you to pay a $1,316 deductible for the hospital stay as well as a 20 percent deductible for physician services that are reimbursed under Medicare Part B.

      What is unique about kidney transplantation is that Medicare will also cover the full costs of care for a living donor. Neither you nor the donor will need to pay a single penny out of pocket for their care, even if there are complications from the procedure.

      After you get a kidney transplant, you will need to be put on immunosuppressive drugs for the rest of your life. These drugs are required to prevent your body from rejecting the transplanted kidney. Medicare will pay for these medications as long as Medicare covered your kidney transplant (i.e., you were on Medicare Part A) and as long as you continue to have Medicare Part B.

      Do not expect Medicare to take care of you after you have a kidney transplant though, at least not for the long haul. They will provide coverage for 36 months after a Medicare-approved transplant. After that, if your new kidney remains functional, you will no longer be eligible for Medicare, and you will lose your coverage. This is the case even though you need to continue on immunosuppressive therapy.

      The only way your benefits will continue is if you are on Medicare for another reason, whether that is by age or another disability.

      A Word From Verywell

      Kidney disease is a growing problem in our country, risking the lives of more than 600,000 Americans. Understanding who Medicare covers, when coverage begins, and how much you will be expected to pay for those services is part of the puzzle. Know your rights and get the best care at the right time.

      Sources:

      Annual Data Report 2016 - Chapter 11: Medicare Expenditures for Persons With ESRD. United States Renal Data System website. https://www.usrds.org/2015/view/v2_11.aspx. Published 2016.

      End Stage Renal Disease in the United States. National Kidney Foundation website. https://www.kidney.org/news/newsroom/factsheets/End-Stage-Renal-Disease-in-the-US. Published January 2016.

      Kidney Disease Statistics in the United States. National Institute of Diabetes and Digestive and Kidney Diseases website. https://www.niddk.nih.gov/health-information/health-statistics/Pages/kidney-disease-statistics-united-states.aspx. Published December 2016.

      The Kidney Transplant Waitlist – What You Need to Know. National Kidney Foundation website. https://www.kidney.org/atoz/content/transplant-waitlist. Updated February 10, 2017.

      Medicare Coverage of Kidney Dialysis and Kidney Transplant Services. Centers for Medicare and Medicaid Services website. https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf. Revised May 2016.

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