Medicare's Coverage of Dialysis & Kidney Transplant Benefits

Who Should Read This

This publication is written for people of any age who have been diagnosed with End-Stage Renal Disease (ESRD) — the medical term for permanent kidney failure that requires dialysis or a kidney transplant to survive. It is especially useful for those who are newly diagnosed, recently started dialysis, or are considering a kidney transplant and want to understand how Medicare can help pay for their care.

Family members, caregivers, and adult children who help a loved one navigate their health care decisions will also benefit from reading this. Since ESRD Medicare eligibility is not limited to people 65 and older, younger adults under 65 living with kidney failure should read this as well. Anyone managing ESRD-related costs and looking for ways to reduce out-of-pocket expenses will find the coverage and cost information here especially helpful.

Quick Overview

This CMS publication, titled 'Medicare's Coverage of Kidney Dialysis and Kidney Transplant Benefits: Getting Started,' gives people with ESRD a clear starting point for understanding what Medicare covers, when coverage begins, what costs to expect, and how to file complaints about care quality. It covers both Original Medicare and Medicare Advantage options, and explains the roles of Medicare Part A and Part B in covering dialysis and transplant services.

The publication is a concise, two-page fact sheet (CMS Product No. 11360, updated January 2024). It directs readers who need more detail to the companion full booklet, 'Medicare Coverage of Kidney Dialysis and Kidney Transplant Services' (CMS Product No. 10128).

Key Takeaways

• People with ESRD can qualify for Medicare at any age — not just at 65 — as long as they meet Social Security work history requirements.
• If you are under 65 and qualify for Medicare only because of ESRD, your coverage usually begins on the first day of the fourth month of your dialysis treatments.
• You need both Medicare Part A and Part B to get full coverage for dialysis and kidney transplant services under Original Medicare.
• Under Original Medicare, after you pay the Part B yearly deductible, Medicare pays 80% of covered dialysis-related services and you pay the remaining 20% coinsurance.
• Medicare only covers kidney transplants performed at Medicare-certified hospitals, and Part B covers immunosuppressive (anti-rejection) drugs after the transplant — with the possibility of extended coverage beyond 36 months under certain conditions.
• If you have Medicare only because of ESRD, your coverage ends 12 months after stopping dialysis or 36 months after a kidney transplant, though it may resume under certain conditions.
• You have the right to file complaints about your dialysis or transplant care with your ESRD Network or State Survey Agency, and your facility cannot take action against you for filing a complaint.

Publication Summary

Medicare provides broad coverage for people living with End-Stage Renal Disease, which is the medical term for permanent kidney failure. ESRD coverage is unique because it is not tied to age — people under 65 can qualify for Medicare if they or a family member has paid enough into Social Security and they have been diagnosed with ESRD. People with ESRD can choose between Original Medicare (Parts A and B) or a Medicare Advantage Plan for their coverage.

Dialysis coverage under Medicare is divided between Part A and Part B depending on where treatment takes place. Part A covers dialysis treatments when a patient is admitted to a hospital as an inpatient. Part B picks up the broader range of dialysis services, including outpatient treatments at a Medicare-certified dialysis facility, dialysis performed at home, home dialysis training, equipment, supplies, and most drugs used for outpatient and home dialysis — including medications to treat anemia related to kidney disease. Laboratory tests ordered as part of dialysis care are also covered, and there is no out-of-pocket cost for Medicare-approved lab work. One important limitation: Medicare does not pay for transportation to dialysis facilities in most cases unless it is a medical emergency requiring an ambulance.

For kidney transplants, Medicare covers the surgery only when it is performed at a hospital that is Medicare-certified to conduct kidney transplants. Part A covers inpatient hospital services, the kidney registry fee, lab work to evaluate the patient and potential donors, the costs of locating a compatible kidney when no donor is available, and certain care costs for the donor — including any extra hospital care needed if the donor experiences complications. Part B covers the surgeon's fees for both the transplant recipient and the donor during the hospital stay, as well as immunosuppressive drugs (also called transplant drugs or anti-rejection medications) for a period of time after leaving the hospital. Notably, a Part B benefit introduced in 2023 may allow coverage of immunosuppressive drugs beyond 36 months for patients who do not have or expect to enroll in certain other health coverage — though this benefit covers only those drugs and not full health coverage.

What you pay depends on whether you have Original Medicare or a Medicare Advantage Plan. Under Original Medicare, after meeting the Part B yearly deductible, you pay 20% coinsurance on covered dialysis-related services while Medicare pays the remaining 80%. For inpatient hospital stays, Part A cost-sharing also applies, including deductibles and coinsurance depending on the length of your stay. Blood and Medicare-approved laboratory tests have specific cost rules — in most cases, the hospital receives blood from a blood bank at no charge, so you will not have to pay for it or replace it. If you are in a Medicare Advantage Plan, your costs may differ, so checking your plan documents or calling your plan directly is important.

The publication also addresses when Medicare coverage ends for ESRD-only enrollees. If you have Medicare solely because of ESRD, coverage ends 12 months after the month you stop dialysis treatments, or 36 months after the month of your kidney transplant. Coverage may resume if you meet certain conditions, such as restarting dialysis or receiving another transplant.

Other sources of financial help are available beyond Medicare. These include employer or retiree coverage, Medicare Supplement Insurance (Medigap), Medicaid, and Veterans Administration benefits. State Health Insurance Assistance Programs (SHIP) can help answer questions about what coverage options are available in your state. Finally, the publication outlines your rights as a Medicare beneficiary — including the right to appeal decisions and to file complaints with ESRD Networks or State Survey Agencies about the quality of care received at a dialysis facility or transplant center.

Frequently Asked Questions

Do I have to be 65 or older to get Medicare coverage for dialysis or a kidney transplant?
No. People of any age with ESRD may qualify for Medicare as long as they — or a spouse or parent — have worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee. Age is not a requirement for ESRD Medicare eligibility.

When does my Medicare coverage start if I am under 65 and newly diagnosed with ESRD?
In most cases, Medicare coverage begins on the first day of the fourth month of your dialysis treatments. However, if you are enrolled in a home dialysis training program at a Medicare-certified facility during your first three months of dialysis, coverage may begin as early as the first month of treatment.

What does Medicare pay for after a kidney transplant?
Part A covers the inpatient hospital stay, the kidney registry fee, lab tests, and the costs related to finding and caring for the kidney donor. Part B covers the surgeon's fees and immunosuppressive (anti-rejection) drugs after you leave the hospital. There is also a Part B benefit that may extend coverage of immunosuppressive drugs beyond 36 months if you do not have and do not expect to enroll in certain other health coverage.

What will I pay out of pocket for dialysis under Original Medicare?
After paying the Part B yearly deductible, you pay 20% coinsurance for covered dialysis-related services. Medicare pays the remaining 80%. There is no out-of-pocket cost for Medicare-approved laboratory tests related to dialysis. If you are admitted to a hospital for dialysis, Part A cost-sharing applies instead.

What can I do if I have a complaint about my dialysis facility or transplant center?
You can file a complaint with your ESRD Network — the organization that monitors and works to improve care quality for ESRD patients in your area. You can file directly with the Network rather than your facility, and you can remain anonymous if you choose. Your facility cannot take any action against you for filing a complaint. Call 1-800-MEDICARE (1-800-633-4227) to get the ESRD Network phone number for your state.

Access the Full Publication

Publication number: CMS Product No. 11360
Date: January 2024
Length: 4 pages