C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S 

Medicare Coverage of 

Kidney Dialysis & Kidney 

Transplant Services 

This official government booklet explains: 

The basics of Medicare 

How Medicare helps pay for kidney 

dialysis and kidney transplants 

Where to get help 
The information in this booklet was correct when it was printed. 

Changes may occur after printing. Visit www.medicare.gov or 

call 1-800-MEDICARE (1-800-633-4227) to get the most current 

information. TTY users should call 1-877-486-2048. 

“Medicare Coverage of Kidney Dialysis & Kidney Transplant Services” 

isn’t a legal document. Official Medicare Program legal guidance is 

contained in the relevant statutes, regulations, and rulings.
3

Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Section 1: Medicare Basics . . . . . . . . . . . . . . . . . . . . . . . .7

What is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

What Medicare covers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

What Medicare costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Part A costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Part B costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Paying for Part B . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Who’s eligible? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Medicare plan choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

How to sign up for Medicare . . . . . . . . . . . . . . . . . . . . . . . . . 10

When Medicare coverage begins . . . . . . . . . . . . . . . . . . . . . . . 11

When Medicare coverage ends . . . . . . . . . . . . . . . . . . . . . . . . 12

How Medicare works with employer or union group health plan coverage . . . . . 13

When the 30-month coordination period starts . . . . . . . . . . . . . . . 13

When the 30-month coordination period ends . . . . . . . . . . . . . . . 14

How the 30-month coordination period works if you enroll in Medicare 

more than once . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Do I have to get Medicare if I already have an employer or union group 

health plan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

For more information about how employer or union group health plan 

coverage works with Medicare . . . . . . . . . . . . . . . . . . . . 15

Medicare for children with ESRD . . . . . . . . . . . . . . . . . . . . . . . 16

Section 2: Kidney Dialysis . . . . . . . . . . . . . . . . . . . . . . . 17

What is dialysis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Dialysis treatment options . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Dialysis services and supplies covered by Medicare . . . . . . . . . . . . . . . . 18

Home dialysis services and supplies NOT covered by Medicare . . . . . . . . . . . 19

Medicare payment system for dialysis services . . . . . . . . . . . . . . . . . 20

What’s included in the new payment system . . . . . . . . . . . . . . . . . . 20
4

What YOU pay for dialysis services in a dialysis facility under the new 

payment system . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Medicare payment for children with ESRD . . . . . . . . . . . . . . . . . . . 21

Training for self-dialysis at home . . . . . . . . . . . . . . . . . . . . . . . 22

Doctors’ self-dialysis training services . . . . . . . . . . . . . . . . . . . 22

Home dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Monthly doctor visits for home dialysis . . . . . . . . . . . . . . . . . . . 22

How long will Medicare pay for home dialysis equipment? . . . . . . . . . . 23

Dialysis in a hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Inpatient doctors’ services . . . . . . . . . . . . . . . . . . . . . . . . 23

Outpatient doctors’ services . . . . . . . . . . . . . . . . . . . . . . . 23

Where to get dialysis treatments . . . . . . . . . . . . . . . . . . . . . . . 24

How to find a dialysis facility . . . . . . . . . . . . . . . . . . . . . . . . . 24

“Dialysis Facility Compare” . . . . . . . . . . . . . . . . . . . . . . . . 24

Knowing how well your dialysis is working . . . . . . . . . . . . . . . . . . . 25

Dialysis when you travel . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Transportation to dialysis facilities . . . . . . . . . . . . . . . . . . . . . . . 27

Section 3: Kidney Transplants . . . . . . . . . . . . . . . . . . . . . 29

What is a kidney transplant? . . . . . . . . . . . . . . . . . . . . . . . . . 29

Kidney transplant services covered by Medicare . . . . . . . . . . . . . . . . . 30

Transplant drugs (called immunosuppressive drugs) . . . . . . . . . . . . . . . 31

What are immunosuppressive drugs? . . . . . . . . . . . . . . . . . . . 31

What if I stop taking my transplant drugs? . . . . . . . . . . . . . . . . . 31

How long will Medicare pay for transplant drugs? . . . . . . . . . . . . . . 31

What if I can’t pay for the transplant drugs? . . . . . . . . . . . . . . . . . 32

Special information about pancreas transplants . . . . . . . . . . . . . . . . . 32

What YOU pay for kidney transplant services . . . . . . . . . . . . . . . . . . 33

Do I have to pay for my kidney donor? . . . . . . . . . . . . . . . . . . . 33

Hospital services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Doctors’ services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Clinical laboratory services . . . . . . . . . . . . . . . . . . . . . . . . 34

Section 4: How Medicare Pays for Blood . . . . . . . . . . . . . . 35

What YOU pay for blood . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Having blood donated . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Can I be charged for the blood that I have donated? . . . . . . . . . . . . . 36

Table of Contents 
5

Section 5: Medicare Prescription Drug Coverage . . . . . . . . . 37

What it costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Extra Help for those who need it most . . . . . . . . . . . . . . . . . . . . . 38

How do I apply for Extra Help? . . . . . . . . . . . . . . . . . . . . . . 38

When you can join . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Section 6: Appeals & Grievances . . . . . . . . . . . . . . . . . . . 41

Your Medicare rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Appeal rights in Original Medicare . . . . . . . . . . . . . . . . . . . . . . . 41

Appeal rights in a Medicare health plan . . . . . . . . . . . . . . . . . . . . 42

Filing a grievance (complaint) . . . . . . . . . . . . . . . . . . . . . . . . . 42

Section 7: Other Kinds of Health Insurance . . . . . . . . . . . . 43

Employee or retiree coverage from an employer or union . . . . . . . . . . . . . 43

Medicare Supplement Insurance (Medigap) policies . . . . . . . . . . . . . . . 44

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Veterans’ benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Other ways to get help . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Section 8: Where to Get More Information . . . . . . . . . . . . 47

Kidney organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

End-Stage Renal Disease (ESRD) Networks . . . . . . . . . . . . . . . . . . . 48

State Health Insurance Assistance Programs (SHIP) . . . . . . . . . . . . . . . 48

State Survey Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Other Medicare products for kidney patients . . . . . . . . . . . . . . . . . . 49

Important phone numbers . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Section 9: Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Table of Contents 
6

Introduction

Learning that you have permanent kidney 

failure isn’t easy. Even though you may 

feel sad, confused, or frustrated, you can 

still take control of your life. The fact that 

you’re reading this booklet is a start. 

This booklet explains how Medicare helps pay for 

kidney dialysis and kidney transplant services in 

Original Medicare. In most cases, you can’t join a 

Medicare Advantage Plan (like an HMO or PPO) if 

you have End-Stage Renal Disease. See page 9. If you’re 

in a Medicare Health Plan, your plan must give you at 

least the same coverage that Original Medicare gives, 

but your costs, rights, protections, and/or choices of 

where you get your care may be different. You may 

also be able to get extra benefits. You can read this 

booklet to understand what Medicare covers, but you’ll 

need to read your plan materials or call your benefits 

administrator for more information about plan rules. 

Talk with your health care team to learn more about 

permanent kidney failure and your treatment options. 

Your doctors, nurses, social workers, dieticians, and 

dialysis technicians make up your health care team. 

They are there to help you decide what’s best for you 

based on your situation. 

If you have questions about Medicare after reading 

this booklet, visit www.medicare.gov, or call 

1-800-MEDICARE (1-800-633-4227). TTY users should 

call 1-877-486-2048. 
7

Words in red

are defined on 

pages 53–54. 

Section 1: Medicare Basics 

What is Medicare? 

Medicare is health insurance for: 

■ People 65 and older 

■ People under 65 with certain disabilities 

■ People of any age with End-Stage Renal Disease (ESRD) (permanent kidney 

failure requiring dialysis or a kidney transplant) 

What Medicare covers 

Medicare Part A (Hospital Insurance) helps cover: 

■ Inpatient care in hospitals 

■ Inpatient care in skilled nursing facilities (not custodial or long-term care) 

■ Hospice care 

■ Home health care 

Medicare Part B (Medical Insurance) helps cover: 

■ Services from doctors and other health care providers

■ Outpatient care 

■ Home health care 

■ Some preventive services 

For more details about what Medicare covers, visit www.medicare.gov, or call 

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 

What Medicare costs 

Part A costs 

Most people don’t have to pay a monthly premium for Part A because they (or a 

spouse) paid Medicare taxes while they were working. 

Part B costs 

Most people must pay a monthly premium for Part B. The standard Part B 

premium for 2012 is $99.90 per month, although it may be higher based on 

your income. Premium rates can change yearly. You need Part B to get the full 

benefits available under Medicare for people with ESRD, and you must pay 

the premium to get Part B. For more information about the Part B premium, 

visit www.socialsecurity.gov, or call Social Security at 1-800-772-1213. TTY users 

should call 1-800-325-0778. 
8 Section 1—Medicare Basics 

Paying for Part B 

When you sign up for Part B, the premium is usually taken 

out of your monthly Social Security or Railroad Retirement 

payment. If you don’t get one of these payments, Medicare 

sends you a bill for your Part B premium every 3 months. 

You should get your Medicare premium bill by the 10th of 

the month. If you don’t get your bill by the 10th, call Social 

Security. 

Who’s eligible? 

You can get Medicare no matter how old you are if your kidneys 

no longer work, you need regular dialysis or have had a kidney 

transplant, and: 

■ You’ve worked the required amount of time under Social Security, 

the Railroad Retirement Board, or as a government employee. 

■ You’re already getting or are eligible for Social Security or Railroad 

Retirement benefits. 

■ You’re the spouse or dependent child of a person who meets either 

of the requirements listed above. 

You must also file an application, and meet any waiting periods 

that apply.

If you qualify for Part A, you can also get Part B. As noted above, 

enrolling in Part B is your choice, but you’ll need both Part A and 

Part B to get the full benefits available under Medicare to cover 

certain dialysis and kidney transplant services.

If you don’t qualify for Medicare, you may be able to get help from 

your state to pay for your dialysis treatments. See pages 45–46. 

Call Social Security at 1-800-772-1213 for more information 

about the required amount of time needed under Social Security, 

the Railroad Retirement Board, or as a government employee to 

be eligible for Medicare based on ESRD. TTY users should call 

1-800-325-0778. You can also visit www.socialsecurity.gov. 
Section 1—Medicare Basics 9

Medicare plan choices 

Medicare generally offers different choices for how you can get your 

health and prescription drug coverage, although the choices may be 

limited if you have ESRD. Your costs will vary depending on your 

coverage and the services you use. 

If you have ESRD and you’re new to Medicare, you’ll most likely 

get your health care through Original Medicare. Original Medicare 

is managed by the Federal government. You can go to any doctor or 

supplier that’s enrolled in and accepts Medicare and is accepting new 

Medicare patients, or to any participating hospital or other facility. 

You pay a set amount for your health care (deductible) before Medicare 

pays its share. Then, Medicare pays its share, and you pay your share 

(coinsurance or copayment) for covered services and supplies. 

When you have Original Medicare, you can add prescription drug 

coverage by joining a Medicare Prescription Drug Plan (Part D). 

Private companies approved by Medicare run these plans. Different 

plans cover different drugs, but most medically-necessary drugs must 

be covered. See pages 37–39 for more information about Medicare 

Prescription Drug Plans. 

You usually can’t join a Medicare Advantage Plan (like an HMO or 

PPO) if you already have ESRD, and haven’t had a kidney transplant. 

However, you may be able to join a Medicare Special Needs Plan, a 

type of Medicare Advantage Plan for people with certain chronic 

diseases, if one is available in your area for people with ESRD. These 

plans must provide all Part A and Part B health care and services, as 

well as Medicare prescription drug coverage. You also may be able to 

join a Medicare Advantage Plan if you’re already getting your health 

benefits (for example, through an employer health plan) through the 

same organization that offers the Medicare Advantage Plan. While 

you’re in a Medicare Advantage Plan, the plan will be the primary 

provider of your health care coverage. You must use your Medicare 

Advantage Plan ID card instead of your red, white, and blue Medicare 

card when you see your doctor or get other kinds of health care 

services. 
10 Section 1—Medicare Basics 

If you had ESRD, but have had a kidney transplant, and you still qualify for 

Medicare benefits based on your age or a disability, you can stay in Original 

Medicare, or join a Medicare Advantage Plan. 

If you have ESRD and are enrolled in a Medicare Advantage Plan that 

stops being offered in your area, you have a one-time right to join another 

Medicare Advantage Plan if one is available in your area. You don’t have 

to use your one-time right to join a new plan immediately. If you change 

directly to Original Medicare after your plan stops providing coverage, you 

will still have a one-time right to join a Medicare Advantage Plan at a later 

date as long as the plan you choose is accepting new members. 

For more information about your Medicare plan choices, 

look at your “Medicare & You” handbook. You can visit 

www.medicare.gov/publications to view the handbook. You can also 

call 1-800-MEDICARE (1-800-633-4227) to get more information. 

TTY users should call 1-877-486-2048. 

How to sign up for Medicare 

If you’re eligible for Medicare because of ESRD, you can enroll in Part A 

and Part B by visiting your local Social Security office or by calling Social 

Security at 1-800-772-1213. TTY users should call 1-800-325-0778. 

If you qualify for Part A, you’ll also be offered Part B. As noted above, you 

need both parts to get all the Medicare benefits available for ESRD, and 

there’s a premium for Part B. If you decide not to get Part B right away, you 

can only enroll January 1–March 31 each year. Your coverage will begin on 

July 1. Also, the cost of Part B will go up 10% for each 12-month period that 

you could have had Part B but didn’t sign up for it. If you have employer or 

union group health plan coverage, see pages 13–15. 

Note: If you’re already enrolled in Medicare based on age or disability, and 

you’re already paying a higher Part B premium because you didn’t enroll in 

Part B when you were first eligible, the penalty will stop when you become 

entitled to Medicare based on ESRD. Call your local Social Security office to 

make an appointment to re-enroll in Medicare based on ESRD. 

Medicare plan choices (continued) 
Section 1—Medicare Basics 11

When Medicare coverage begins 

When you enroll in Medicare based on ESRD and you’re on dialysis, 

Medicare coverage usually starts the first day of the fourth month of 

your dialysis treatments. For example, if you start getting your dialysis 

treatments in July, your Medicare coverage would start on October 1. 

July August September October

First month of 

dialysis 

Second month 

of dialysis

Third month 

of dialysis

Fourth month of 

dialysis. Medicare 

coverage begins.

If you’re covered by an employer or union group health plan, for the 

first 30 months you’re covered by Medicare, your employer or union 

group health plan will pay first on your health care bills, and Medicare 

will pay second. For more detailed information, see pages 13–15. 

If you don’t have employer group health plan coverage, there are 

other types of insurance and programs that may help to pay some 

of your health care costs. See pages 44–46. 

Medicare coverage can start as early as the first month of dialysis if 

you meet all of the following conditions:

■ You take part in a home dialysis training program offered by 

a Medicare-approved training facility to teach you how to give 

yourself dialysis treatments at home. 

■ Your doctor expects you to finish training and be able to do your 

own dialysis treatments. 

Medicare coverage begins the month you get a kidney transplant. 

Medicare coverage can begin the month you’re admitted to a 

Medicare-approved hospital for a kidney transplant (or for health care 

services that you need before your transplant) if your transplant takes 

place in that same month or within the following 2 months. 

Example: Mr. Green will be admitted to the hospital on March 11 for 

his kidney transplant. His Medicare coverage will begin in March. 

If his transplant is delayed until April or May, his Medicare coverage 

will still begin in March. 
12 Section 1—Medicare Basics 

Important: Medicare won’t cover surgery or other services needed to prepare 

for dialysis (such as surgery for a blood access [fistula]) before Medicare 

coverage begins. However, if you complete home dialysis training, your 

Medicare coverage will start the month you begin regular dialysis, and these 

services could be covered. 

Medicare coverage can begin 2 months before the month of your 

transplant if your transplant is delayed more than 2 months after you’re 

admitted to the hospital for the transplant or for health care services you 

need before your transplant. 

Example: Mrs. Perkins was admitted to the hospital on May 25 for some 

tests she needed before her kidney transplant. She was supposed to get 

her transplant on June 15. However, her transplant was delayed until 

September 17. Therefore, Mrs. Perkins’ Medicare coverage will start in July, 

2 months before the month of her transplant. 

Note: This waiting period will start even if you haven’t signed up for Medicare. 

For example, if you don’t sign up until after you’ve met all the requirements, 

your coverage could begin up to 12 months before the month you apply. 

When Medicare coverage ends 

If you’re eligible for Medicare only because of permanent kidney failure, your 

Medicare coverage will end: 

■ 12 months after the month you stop dialysis treatments 

■ 36 months after the month you have a kidney transplant 

Your Medicare coverage will be extended if: 

■ You start dialysis again, or you get a kidney transplant within 12 months 

after the month you stopped getting dialysis 

■ You start dialysis or get another kidney transplant within 36 months after 

the month you get a kidney transplant 

Important: Remember, you need both Part A and Part B to get the 

benefits available under Medicare for people with ESRD. If you don’t 

pay your Part B premium or if you choose to cancel it, your Part B 

coverage will end.

When Medicare coverage begins (continued) 
Section 1—Medicare Basics 13

How Medicare works with employer or union group health plan 

coverage 

If you’re eligible for Medicare only because of permanent kidney failure, 

your eligibility usually can’t start until the fourth month of dialysis. This 

means if you have coverage under an employer or union group health plan, 

that plan will be the only payer for the first 3 months of dialysis (unless you 

have other insurance). 

If your employer or union plan doesn’t pay all costs for dialysis, you 

may have to pay some of the costs. You may be able to get help paying 

these costs. See pages 44–46. 

Once you become eligible for Medicare because of permanent kidney failure 

(usually the fourth month of dialysis), there will still be a period of time, 

called a “coordination period,” when your employer or union group health 

plan will continue to pay your health care bills. However, if your plan 

doesn’t pay 100% of your health care bills, Medicare may pay some of the 

remaining costs. This is called “coordination of benefits,” under which your 

plan “pays first” and Medicare “pays second.” During this time, Medicare is 

called the secondary payer. This coordination period lasts for 30 months. 

When the 30-month coordination period starts 

The waiting period for eligibility will start even if you haven’t signed up 

for Medicare. The same thing is true of the 30-month coordination period, 

which starts the first month you would be eligible to get Medicare because 

of permanent kidney failure (usually the fourth month of dialysis), even if 

you haven’t signed up for Medicare yet. For example, if you start dialysis 

and are eligible for Medicare in June, the 30-month coordination period 

will start September 1, the fourth month of dialysis even if you don’t have 

Medicare. 

If you take a course in self-dialysis training or get a kidney transplant 

during the 3-month waiting period, the 30-month coordination period will 

start earlier. During this 30-month period, Medicare will be the secondary 

payer. 

Important: If you have employer or union group health plan coverage, 

tell your health care provider that you have this coverage. This is very 

important to make sure that your services are billed correctly. 
14 Section 1—Medicare Basics 

When the 30-month coordination period ends 

At the end of the 30-month coordination period, Medicare will 

pay first for all Medicare-covered services. Your employer or union 

group health plan coverage may still pay for services not covered by 

Medicare. Check with your plan’s benefits administrator. 

How the 30-month coordination period works if you enroll in Medicare more 

than once 

There’s a separate 30-month coordination period each time you 

enroll in Medicare based on permanent kidney failure. For example, 

if you get a kidney transplant that continues to work for 36 months, 

your Medicare coverage will end (unless you have Medicare because 

you’re 65 or older or you have a certain disability). If after 36 months 

you enroll in Medicare again because you start dialysis or get 

another transplant, your Medicare coverage will start right away. 

There will be no 3-month waiting period before Medicare begins to 

pay. However, there will be a new 30-month coordination period if 

you have employer or union group health plan coverage. 

Do I have to get Medicare if I already have an employer or union group 

health plan? 

No, but you should think carefully about this decision. If you get a 

kidney transplant, you’ll need to take immunosuppressive drugs for 

the rest of your life, so it’s important to know if they’ll be covered. 

If you’re entitled to Medicare only because of ESRD (you’re not over 

65 or disabled), Part B will only cover your immunosuppressive 

drugs (see pages 30–32) if you already had Part A at the time of 

the transplant, and the transplant surgery was performed at a 

Medicare-approved facility. 

Note that Part B will only cover the immunosuppressive drugs after 

you’re enrolled in Part B. There won’t be any retroactive coverage. 

Note: If you don’t meet the conditions for Part B coverage of 

immunosuppressive drugs, you may be able to get coverage by 

joining a Medicare Prescription Drug Plan. See pages 37–39. 

How Medicare works with employer or union group health 

plan coverage (continued) 
Section 1—Medicare Basics 15

If your group health plan coverage has a yearly deductible, 

copayment, or coinsurance, enrolling in Part A and Part B could 

help pay those costs during the coordination period. 

If your group health plan coverage will pay for most or all of your 

health care costs (for example, if it doesn’t have a yearly deductible), 

you may want to delay enrolling in Part A and Part B until the 

30-month coordination period is over. If you delay enrollment, you 

won’t have to pay the Part B premium for coverage you don’t need 

yet. After the 30-month coordination period, you should enroll in 

Part A and Part B. Your Part B premium won’t be higher because 

you delayed your enrollment. If your group health plan benefits are 

decreased or end during this period, you should enroll in Part A and 

Part B as soon as possible. 

For more information about how employer or union group health plan 

coverage works with Medicare 

■ Get a copy of your plan’s benefits booklet. 

■ Call your benefits administrator, and ask how the plan pays when 

you have Medicare. 

How Medicare works with employer or union group health 

plan coverage (continued) 
16 Section 1—Medicare Basics 

Medicare for children with ESRD 

Medicare covers people of all ages who have ESRD. 

Your child can be covered if you or your spouse has 

worked the required amount of time under Social 

Security, the Railroad Board, or as a government 

employee. Your child can also be covered if you, 

your spouse, or the child gets Social Security or 

Railroad Retirement benefits. Medicare can help 

cover your child’s medical costs if your child needs 

regular dialysis because his or her kidneys no longer 

work, or if he or she has had a kidney transplant. 

Use the information in this booklet to help answer your questions, or 

visit www.medicare.gov/publications to view the brochure “Medicare 

for Children with End-Stage Renal Disease: Getting Started.” You can 

also contact your local Social Security office, or call 1-800-772-1213. 

TTY users should call 1-800-325-0778. 
17

Words in red

are defined on 

pages 53–54. 

Section 2: Kidney Dialysis 

What is dialysis? 

Dialysis is a treatment that cleans your blood when your kidneys 

don’t work. It gets rid of harmful waste, extra salt, and fluids that 

build up in your body. It also helps control blood pressure and helps 

your body keep the right amount of fluids. Dialysis treatments help 

you feel better and live longer, but they aren’t a cure for permanent 

kidney failure. 

Dialysis treatment options 

There are 2 types of dialysis treatment options: 

1. Hemodialysis uses a special filter (called a dialyzer) 

to clean your blood. The filter connects to a machine. 

During treatment, your blood flows through tubes into 

the filter to clean out wastes and extra fluids. Then the 

newly-cleaned blood flows through another set of tubes 

back into your body. 

2. Peritoneal dialysis uses a special solution (called 

dialysate) that flows through a tube into your abdomen. 

After a few hours, the dialysate has taken wastes from 

your blood and can be drained from your abdomen. After 

draining the used dialysate, your abdomen is filled with 

fresh dialysate, and the cleaning process begins again. 

You should work with your health care team to decide the type of 

dialysis you need based on your situation. The goal is to help you 

stay healthy and active. 
18 Section 2—Kidney Dialysis 

Dialysis services and supplies covered by Medicare 

Medicare covers the following dialysis services and pays part of their costs: 

Service or supply Covered by 

Medicare 

Part A 

Covered by 

Medicare 

Part B 

Inpatient dialysis treatments (if you’re 

admitted to a hospital for special care) ✔

Outpatient dialysis treatments (if you 

get treatments in any Medicare-approved 

dialysis facility) 

✔

Outpatient doctors’ services (see page 23) ✔

Self-dialysis training (includes instruction 

for you and the person helping you with 

your home dialysis treatments) 

✔

Home dialysis equipment and supplies

(like the machine, water treatment system, 

basic recliner, alcohol, wipes, sterile drapes, 

rubber gloves, and scissors) (see pages 

22–23) 

✔

Certain home support services (may 

include visits by trained hospital or 

dialysis facility workers to check on your 

home dialysis, to help in emergencies 

when needed, and to check your dialysis 

equipment and water supply) (see page 22) 

✔

Most drugs for home dialysis (see 

page 20) ✔

Other services and supplies that are a 

part of dialysis (like laboratory tests) ✔

To find out what you pay for these services, see pages 21–23. 
Section 2—Kidney Dialysis 19

Home dialysis services and supplies NOT covered by Medicare 

Medicare doesn’t cover the following services or supplies: 

Service or supply Not covered

Paid dialysis aides to help you with home 

dialysis ✗

Any lost pay to you or the person who may 

be helping you during self-dialysis training ✗

A place to stay during your treatment ✗

Blood or packed red blood cells for home 

self-dialysis unless part of a doctors’ service ✗

There are some types of insurance that may pay some of the health care 

costs that Medicare doesn’t pay. See pages 43–46. For more information 

on Medicare prescription drug coverage, see pages 37–39. 
20 Section 2—Kidney Dialysis 

Medicare payment system for dialysis services 

A new payment system called the ESRD Prospective Payment 

System (PPS) went into effect on January 1, 2011. This payment 

system “bundles” or combines all of the Part B ESRD dialysis 

services and items that were previously grouped under the composite 

rate and those ESRD dialysis items or services that were previously 

billed separately. The composite rate is the former method that 

Medicare used to pay dialysis facilities for dialysis-related services. 

What’s included in the new payment system 

The new payment system includes the following Part B covered 

services and items: 

■ Dialysis-related services, equipment, and supplies that were in the 

prior composite rate 

■ Injectable drugs and their oral forms and biologicals, including 

erythropoiesis stimulating agents used for ESRD dialysis 

treatment* 

■ Laboratory tests and other items and services provided for ESRD 

dialysis treatment 

■ Home dialysis training by a Medicare-certified home dialysis 

training facility (if you choose to get dialysis at home) 

*Medications that are only available in oral form will continue to be 

covered under Medicare prescription drug coverage (Part D). Talk 

with your doctor or health care team about the use of any drugs, 

including over-the-counter products. 
Section 2—Kidney Dialysis 21

What YOU pay for dialysis services in a dialysis facility under 

the new payment system 

If you have Original Medicare, you’ll continue to pay 20% of the 

Medicare-approved amount for all covered dialysis related services. 

Medicare will pay the remaining 80%. 

The amount (20%) for which you’re responsible may vary under 

the new payment system. If you’re in a Medicare Advantage Plan

(like an HMO or PPO) or have a Medicare Supplement Insurance 

(Medigap) policy that covers all or part of your 20% coinsurance, 

then your costs may be different. Read your plan materials or call 

your benefits administrator to get your cost information. You must 

also continue to pay your monthly Part B and Part D (if applicable) 

premiums. 

Note: Your 20% copayment covers all of the services and items 

listed on page 20. Since these services and items are included in 

the new bundled payment system, you can’t be billed separately for 

them. You also don’t need to get the drugs that are included in the 

bundle from your Medicare drug plan (if you have one). 

Medicare payment for children with ESRD 

If you have a child under 18 who has Medicare coverage because of 

ESRD, the payment rules are the same as described above. However, 

the rates paid to the dialysis facilities are adjusted based on the 

child’s age and the type of dialysis they get. These adjustments 

allow for the special care needs of children. 
22 Section 2—Kidney Dialysis 

Training for self-dialysis at home 

Training for self-dialysis at home is covered under Part B on an outpatient 

basis, but only in a facility certified for dialysis training. You may qualify 

for training if you think you would benefit from self-dialysis training for 

at-home treatments, and your doctor approves. Training sessions will occur 

at the same time you get dialysis treatment and are subject to a maximum 

number of sessions. 

Doctors’ self-dialysis training services 

In Original Medicare, Medicare pays your kidney doctor a flat fee to 

supervise self-dialysis training. After you pay the Part B yearly deductible

($140 in 2012), Medicare pays 80% of the flat fee and you pay the remaining 

20%. 

Example: (What you pay may be different than what’s shown.) 

Let’s say the flat fee for the doctor who’s supervising the self-dialysis training 

is $500. After you pay the Part B yearly deductible, here are the costs: 

■ Medicare pays 80% of the $500 (or $400). 

■ You pay the remaining 20% coinsurance (or $100). 

Home dialysis 

Your dialysis facility will be responsible for providing all of your home 

dialysis related items and services including equipment and supplies (either 

directly or under arrangement). Under the new payment system, home 

dialysis equipment and supplies provided directly from dialysis suppliers 

(formerly referred to as Method II) are no longer available. However, dialysis 

suppliers may provide equipment and supplies under arrangement with your 

dialysis facility. Medicare pays for home dialysis at the same rate as dialysis 

you get in a facility. 

Monthly doctor visits for home dialysis 

Medicare pays doctors (and certain non-doctors, such as physician assistants 

and nurse practitioners), on a monthly basis, to help people with Medicare 

who perform self-dialysis at home manage their care. This benefit includes 

a face-to-face visit between you and your doctor once a month. The 

face-to-face visit allows you and your doctor to discuss your care and the 

effectiveness of your dialysis, to check for complications, and to give you a 

chance to ask questions about your home dialysis treatment. 
Section 2—Kidney Dialysis 23

How long will Medicare pay for home dialysis equipment? 

Part B will pay for home dialysis equipment as long as you need 

dialysis at home. If you no longer need home dialysis (for example, if 

you had a kidney transplant), Part B would stop paying. 

Dialysis in a hospital 

If you’re admitted to a hospital and get dialysis, your treatments will 

be covered by Part A as part of the costs of your covered inpatient 

hospital stay. 

Inpatient doctors’ services 

In Original Medicare, your kidney doctor bills separately for the 

Medicare-covered ESRD services you get as an inpatient. In this case, 

your kidney doctor’s monthly payment will be based on the number of 

days you stay in the hospital. 

Outpatient doctors’ services 

In Original Medicare, Medicare pays most kidney doctors a monthly 

amount. After you pay the Part B yearly deductible ($140 in 2012), 

Medicare pays 80% of the monthly amount. You pay the remaining 

20% coinsurance. 

In some cases, your doctor may be paid per day if you get services for 

less than 1 month. 

Example: (What you pay may be different than what’s 

shown.)

Let’s say the monthly amount that Medicare pays 

your doctor for each dialysis patient is $125. After you 

pay the Part B yearly deductible, here are the costs: 

■ Medicare pays 80% of the $125 (or $100). 

■ You pay the remaining 20% coinsurance (or $25). 
24 Section 2—Kidney Dialysis 

Where to get dialysis treatments 

Dialysis can be done at home or in a Medicare-certified dialysis facility. 

For Medicare to pay for your treatments, the facility must be approved by 

Medicare to provide dialysis (even if the facility already provides other 

Medicare-covered health care services). 

At the dialysis facility, a nurse or trained technician may give you the 

treatment. At home, you can treat yourself or you can ask a family member 

or friend for help. If you decide to do home dialysis, you and your helper 

(if you have one) will get training. 

If you have a problem with the care you’re getting from your dialysis facility, 

you have the right to file a grievance (complaint) to resolve your problem. 

See page 42, “Filing a grievance (complaint),” for more information. 

How to find a dialysis facility 

In most cases, the facility your kidney doctor works with is where you will 

get dialysis treatments. However, you have the right to choose to get your 

treatments from another facility at any time, but this could mean changing 

doctors. 

You can also call your local ESRD Network (see pages 50–51) to find 

a dialysis facility that’s close to you, or you can use “Dialysis Facility 

Compare” by visiting www.medicare.gov/dialysis. 

“Dialysis Facility Compare” 

“Dialysis Facility Compare” has important information about 

Medicare-certified dialysis facilities in your area and around the country. 

Visit www.medicare.gov/dialysis. You can find information such as addresses 

and phone numbers, how far certain facilities are from you, and what kind 

of dialysis services the facilities offer. You can also compare facilities by the 

services they offer and by certain quality of care information. Helpful Web 

sites, publications, and phone numbers are also available. You can discuss 

the information on this Web site with your health care team. 

If you don’t have a computer, your local library or senior center may be able 

to help you look at this information. You can also call 1-800-MEDICARE 

(1-800-633-4227), or contact your local State Health Insurance Assistance 

Program (see pages 50–51) to get help with comparing dialysis facilities. 

TTY users should call 1-877-486-2048. 
Section 2—Kidney Dialysis 25

Knowing how well your dialysis is working 

With the right type and amount of dialysis, you’ll probably feel better and 

less tired, have a better appetite and less nausea, have fewer hospital stays, 

and live longer. 

You can tell how well the dialysis is working with blood tests that keep 

track of your URR or Kt/V (pronounced “kay tee over vee”) number. 

These numbers tell your doctor or nurse how well dialysis is removing 

wastes from your body. Your doctor or nurse usually keeps track of one or 

both of these numbers, depending on which test your dialysis facility uses. 

A URR of 65% and a Kt/V of 1.2 are the minimum numbers for adequate 

dialysis. Your health care provider or dialysis center may set a higher 

dialysis goal for your health and to make you feel better. Talk to your 

health care provider about your number. 

Even if you feel fine, you should still check how well your dialysis is 

working. 

For a short period of time, you may feel okay without adequate dialysis. 

However, over time, not getting adequate dialysis can make you feel weak 

and tired. It can lead to a higher risk of infection and prolonged bleeding. 

It can shorten your life. 

Here are some steps you can take to get adequate dialysis: 

■ Go to all of your scheduled treatments and arrive on time. 

■ Stay for the full treatment time. 

■ Follow your diet and fluid restrictions. 

■ Follow the advice of your dialysis staff on taking care of yourself. 

■ Check your URR or Kt/V adequacy number every month. 

■ Talk to your doctor about which hemodialysis vascular access* is 

best for you. 

■ Learn how to take care of your vascular access. 

To learn more about how well your dialysis is working, talk with your 

doctor or other health team members at your dialysis facility. 

* Your vascular access is the entrance your doctor makes into your blood 

vessels. During dialysis, your blood is removed and returned through your 

vascular access. 
26 Section 2—Kidney Dialysis 

Dialysis when you travel 

You can still travel within the United States if you need dialysis. 

There are over 5,000 dialysis facilities around the country. Your 

facility can help you plan your treatment along the route of 

your trip before you travel. Your dialysis facility will help you by 

checking to see if the facilities on your route: 

■ Are approved by Medicare to give dialysis 

■ Have the space and time to give care when you need it 

■ Have enough information about you to give you the right 

treatment 

In general, Medicare will only pay for hospital or medical care that 

you get in the United States. 

Note: If you get your dialysis services from a Medicare Advantage 

Plan, your plan may be able to help you arrange to get dialysis while 

you travel. Contact your plan for more information. 
Section 2—Kidney Dialysis 27

Transportation to dialysis facilities 

Medicare covers ambulance services to and from your home to the 

nearest dialysis facility for treatment of ESRD only if other forms 

of transportation would be harmful to your health. 

For non-emergency, scheduled, repetitive ambulance services, the 

ambulance supplier must get a written order from your doctor 

before you get the ambulance service. The doctor’s written order 

must certify that ambulance transportation is medically necessary

and must be dated no earlier than 60 days before you get the 

ambulance service. 

If you’re in a Medicare Advantage Plan, the plan may cover some 

non-ambulance transportation to dialysis centers and doctors. 

Read your plan materials, or call the plan for more information. 

For more information about ambulance coverage, visit 

www.medicare.gov/publications to read or print the booklet 

“Medicare Coverage of Ambulance Services.” You can also call 

1-800-MEDICARE (1-800-633-4227). TTY users should call 

1-877-486-2048. 

Visit www.medicare.gov/dialysis to get information about 

Medicare-certified dialysis facilities in your area. 
28 Section 2—Kidney Dialysis 
29

Words in red

are defined on 

pages 53–54. 

Section 3: Kidney Transplants 

What is a kidney transplant? 

A kidney transplant is a type of surgery that’s done to put a healthy 

kidney from another person into your body. This new kidney does 

the work that your own kidneys can no longer do. You may get a 

kidney from someone who has recently died, or from someone who 

is still living, like a family member. The blood and tissue of the 

person who gives you the kidney must be tested to see how well they 

match yours so that your body won’t reject the new kidney. 

To be covered by Medicare, your kidney transplant must be done in 

a hospital that’s approved by Medicare to do kidney transplants. 

If you have a problem with the care that you’re getting for your 

transplant, you have the right to file a grievance (complaint). See 

page 42, “Filing a grievance (complaint),” for more information. 
30 Section 3—Kidney Transplants 

Kidney transplant services covered by Medicare 

Medicare covers the following transplant services and pays part of 

their costs: 

Service or supply Medicare 

Part A 

Medicare 

Part B 

Inpatient services in an approved hospital ✔

Kidney registry fee ✔

Laboratory and other tests needed to evaluate 

your medical condition* ✔

Laboratory and other tests needed to evaluate the 

medical condition of potential kidney donors* ✔

The costs of finding the proper kidney for your 

transplant surgery (if there’s no kidney donor) ✔

The full cost of care for your kidney donor 

(including care before surgery, the actual surgery, 

and care after surgery) 

✔

Any additional inpatient hospital care for your 

donor in case of problems due to the surgery ✔

Doctors’ services for kidney transplant surgery 

(including care before surgery, the actual surgery, 

and care after surgery) 

✔

Doctors’ services for your kidney donor during 

their hospital stay ✔

Immunosuppressive drugs (for a limited time after 

you leave the hospital following a transplant). See 

pages 31–32. See pages 37–39 for information about 

Medicare Prescription Drug Plans. 

✔

Blood (whole or units of packed red blood cells, 

blood components, and the cost of processing and 

giving you blood). See pages 35–36. 

✔ ✔

To find out what you pay for these services, see pages 33–34. 

* These services are covered whether they are done by the 

Medicare-approved hospital where you will get your transplant, or by 

another hospital that participates in Medicare. 

Note: Buying 

or selling 

human organs 

is against the 

law. Therefore, 

Medicare 

doesn’t pay for 

the kidneys 

used for 

transplant. 
Section 3—Kidney Transplants 31

Transplant drugs (called immunosuppressive drugs) 

What are immunosuppressive drugs? 

Immunosuppressive drugs are transplant drugs used to reduce the 

risk of your body rejecting your new kidney after your transplant. 

You’ll need to take these drugs for the rest of your life. 

Important: You must meet the conditions on page 14 for Medicare 

to cover your immunosuppressive drugs. 

What if I stop taking my transplant drugs? 

If you stop taking your transplant drugs, your body may reject 

your new kidney, and the kidney could stop working. If that 

happens, you may have to start dialysis again. Talk to your doctor 

before you stop taking your transplant drugs. 

How long will Medicare pay for transplant drugs? 

If you’re entitled to Medicare only because of permanent kidney 

failure, your Medicare coverage will end 36 months after the 

month of the transplant. 

Medicare won’t pay for any services or items, including 

immunosuppressive drugs, for patients who aren’t entitled to 

Medicare. 

Medicare will continue to pay for your immunosuppressive drugs 

with no time limit if you: 

■ Were already entitled to Medicare because of age or disability 

before you got ESRD 

■ Became entitled to Medicare because of age or disability after 

getting a transplant that was paid for by Medicare, or paid for by 

private insurance that paid primary to your Part A coverage, in a 

Medicare-certified facility 

If you’re entitled to Medicare only because of permanent 

kidney failure, your Medicare coverage will end when your 

36-month period is over. 
32 Section 3—Kidney Transplants 

Transplant drugs (called immunosuppressive drugs) 

(continued) 

What if I can’t pay for the transplant drugs? 

Transplant drugs can be very costly. If you’re entitled to Medicare 

only because of permanent kidney failure, your immunosuppressive 

drugs are only covered for 36 months after the month of your 

transplant. If you’re worried about paying for them after your 

Medicare coverage ends, talk to your doctor, nurse, or social worker. 

There may be other ways to help you pay for these drugs. See pages 

43–46 to learn more about other health insurance options. 

Special information about pancreas transplants 

If you have ESRD and need a pancreas transplant, Medicare covers 

the transplant if one of the following applies: 

■ It’s done at the same time you get a kidney transplant. 

■ It’s done after a kidney transplant. 

Note: In some rare cases Medicare may cover a pancreas transplant 

even if you don’t need a kidney transplant. 

If you’re entitled to Medicare only because of permanent kidney 

failure, and you have the pancreas transplant after the kidney 

transplant, Medicare will only pay for your immunosuppressive 

drug therapy for 36 months after the month of the kidney transplant. 

This is because your Medicare coverage will end 36 months after 

a successful kidney transplant if you only have Medicare due to 

permanent kidney failure. 

If you were already entitled to Medicare because of age or disability 

before you got ESRD, or if you became eligible for Medicare because 

of age or disability after getting a transplant, Medicare will continue 

to pay for your immunosuppressive drugs with no time limit. 
Section 3—Kidney Transplants 33

What YOU pay for kidney transplant services 

The amounts listed in this section are for transplant services 

covered in Original Medicare. If you’re in a Medicare Advantage 

Plan, your costs may be different. Read your plan materials, or call 

your plan to get information about your costs. 

Do I have to pay for my kidney donor? 

No. Medicare will pay the full cost of care for your kidney donor. 

You don’t have to pay a deductible, coinsurance, or other costs for 

your donor’s hospital stay. 

Hospital services 

If you have Original Medicare, in 2012 you pay: 

■ $1,156 deductible per benefit period

■ $0 for the first 60 days of each benefit period 

■ $289 per day for days 61–90 each benefit period 

■ $578 per lifetime reserve day* after day 90 each benefit period 

(up to 60 days over your lifetime) 

■ All costs for each day after the lifetime reserve days 

For Medicare-approved care in a skilled nursing facility, you pay: 

■ $0 for the first 20 days each benefit period 

■ Up to $144.50 per day for days 21–100 each benefit period 

■ All costs for each day after day 100 in the benefit period 

To find out what you pay for other Part A and Part B services, visit 

www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048. 

*In Original Medicare, lifetime reserve days are additional days 

that Medicare will pay for when you’re in a hospital for more than 

90 days. You have a total of 60 reserve days that can be used during 

your lifetime. For each lifetime reserve day, Medicare pays all 

covered costs except for a daily coinsurance. 
34 Section 3—Kidney Transplants 

Doctors’ services 

In Original Medicare, you must pay the Part B yearly deductible

($140 in 2012). After you pay the deductible, Medicare pays 80% of 

the Medicare-approved amount. You must pay the remaining 20% 

coinsurance. 

Important: There’s a limit on the amount your doctor can charge 

you, even if your doctor doesn’t accept assignment. If your doctor 

doesn’t accept assignment, you only have to pay the part of the bill 

that is up to 15% over the Medicare-approved amount. 

Clinical laboratory services 

You pay nothing for Medicare-approved laboratory tests. 
35

Words in red

are defined on 

pages 53–54. 

Section 4: How Medicare Pays 

for Blood 

In most cases, Medicare Part A and Part B help pay for:

■ Whole blood units or packed red blood cells 

■ Blood components 

■ The cost of processing and giving you blood 

What YOU pay for blood

Under both Part A and Part B, in most cases, the hospital gets 

blood from a blood bank at no charge, and you won’t have to pay 

for it or replace it. If the hospital has to buy blood for you, you 

must either pay the hospital for the first 3 units of whole blood or 

equivalent units of packed red blood cells that you get in a calendar 

year while you’re staying in a hospital or skilled nursing facility or 

replace the blood. See “Having Blood Donated” on the next page. 

You pay a copayment for additional units of blood you get as an 

outpatient (after the first 3), and the Part B deductible applies. 

Note: Once you have paid for or replaced the required units of 

blood, you don’t have to do so again under either Part A or Part B 

for the remainder of the calendar year. 
36 Section 4—How Medicare Pays for Blood 

Having blood donated 

You can replace the blood by donating it yourself, or getting another 

person or organization to donate the blood for you. The blood that’s 

donated doesn’t have to match your blood type. If you decide to donate 

the blood yourself, check with your doctor first. 

Can I be charged for the blood that I have donated? 

No. A hospital or skilled nursing facility can’t charge you for any of the 

first 3 pints of blood you have already donated or will have donated. 

Medicare doesn’t pay for blood for home self-dialysis unless 

it’s part of a doctor’s service or is needed to prime the dialysis 

equipment. 
37

Words in red

are defined on 

pages 53–54. 

Section 5: Medicare 

Prescription Drug Coverage 

Medicare Part B covers immunosuppressive drugs after a covered 

transplant and most of the drugs you get for dialysis. See pages 30–32. 

However, it doesn’t cover prescription drugs for other health conditions 

you may have, like high blood pressure or diabetes. Medicare offers 

prescription drug coverage to help you with the costs of your drugs not 

covered by Part B. 

Medicare prescription drug coverage won’t cover drugs you can 

get under Part B—like immunosuppressive drug therapy under 

the conditions discussed on page 14. However, if you don’t meet 

the conditions on page 14, you may be able to get coverage of your 

immunosuppressive drug therapy by joining a Medicare Prescription 

Drug Plan. 

Medicare prescription drug coverage (Part D) is offered by private 

companies approved by Medicare. There are 2 types of Medicare plans 

that provide Medicare prescription drug coverage: 

■ Medicare Prescription Drug Plans that add coverage to Original 

Medicare or certain types of Medicare health plans. 

■ Medicare prescription drug coverage provided as part of Medicare 

Advantage Plans (like an HMO or PPO). Most people with ESRD can 

only get prescription drug coverage through a Medicare Advantage 

Plan if they already belong to a plan, or if they switch to a different plan 

offered by the same company. 

What it costs 

Most Medicare drug plans charge a monthly premium that varies by 

plan. Your premium may be higher based on your income. You pay the 

Part D premium in addition to the Part B premium. Some plans have 

no premium at all. Your costs will vary depending on which drugs you 

use and which drug plan you choose. Also, if you have limited income 

and resources, you may be able to get Extra Help paying for your Part D 

prescription drug costs. See page 38. Look at your “Medicare & You” 

handbook to get detailed information about prescription drug coverage 

costs. 
38 Section 5—Medicare Prescription Drug Coverage 

Extra Help for those who need it most 

Medicare provides Extra Help to pay prescription drug costs for people 

who meet specific income and resource limits. Resources include your 

savings and stocks, but not your home or car. If you qualify, you’ll get 

help paying for your Medicare drug plan’s monthly premium, yearly 

deductible, and prescription copayments or coinsurance. 

To qualify for Extra Help, your yearly income must be below $16,755 

($22,695 for a married couple living together), and your resources may 

be up to $13,070 ($26,120 for a married couple living together). These 

amounts may change in 2013. 

If you live in Alaska or Hawaii, or pay more than half of the living 

expenses of dependent family members, your income limits are higher. 

Resources don’t include your home, car, household items, burial plot, 

up to $1,500 for burial expenses (per person) or life insurance policies. 

Note: Puerto Rico, the Virgin Islands, Guam, the Northern Mariana 

Islands, and American Samoa provide their residents help with 

Medicare drug costs. This help isn’t the same as the Extra Help 

described here. Call your local Medical Assistance (Medicaid) office to 

learn more. 

How do I apply for Extra Help? 

Some people with Medicare automatically qualify for Extra Help and 

will get a letter from Medicare. 

If you didn’t automatically qualify, call Social Security at 

1-800-772-1213, visit www.socialsecurity.gov, or apply at your 

State Medical Assistance (Medicaid) office. TTY users should call 

1-800-325-0778. After you apply, you will get a letter in the mail letting 

you know if you qualify and what to do next. Even if you don’t qualify, 

you should still consider joining a Medicare Prescription Drug Plan. 

If you apply and qualify for Extra Help, you can either join a plan on 

your own or let Medicare enroll you in a plan. Medicare will send you 

a letter letting you know what plan it will enroll you in and when your 

coverage begins. Check to see if the plan you’re enrolled in covers the 

drugs you use and if you can go to the pharmacies you want. If not, 

you can change plans at any time. 
Section 5—Medicare Prescription Drug Coverage 39

When you can join 

If you become entitled to Medicare based on ESRD, your first 

chance to join a Medicare drug plan will be during the 7-month 

period that begins 3 months before the month you’re entitled to 

Medicare and ends 3 months after the first month you’re entitled to 

Medicare. 

Your prescription drug coverage will start the same time your 

Medicare coverage begins or the first month after you make your 

request, whichever is later. See page 11. 

If you don’t join when you’re first eligible, you can 

join between October 15–December 7 each year. Your 

coverage will begin on January 1 of the following year. 

If you join after your initial enrollment period is over 

and there was a period of 63 continuous days or more 

during which you didn’t have creditable prescription drug 

coverage (coverage that is expected to pay, on average, 

at least as much as Medicare’s standard prescription 

drug coverage), you may have to pay a late enrollment 

penalty. This amount increases the longer you go without 

creditable coverage. You will have to pay this penalty as 

long as you have Medicare prescription drug coverage. 

However, if you get Extra Help, you don’t have to pay a 

late enrollment penalty. 

For more information about Medicare prescription drug 

coverage, visit www.medicare.gov, or call 1-800-MEDICARE 

(1-800-633-4227). TTY users should call 1-877-486-2048. You can 

also contact your local State Health Insurance Assistance Program. 

See pages 50–51. 
40 Section 5—Medicare Prescription Drug Coverage 
41

Words in red

are defined on 

pages 53–54. 

Your Medicare rights 

If you have Medicare, you have certain guaranteed rights to help 

protect you. One of these is the right to a process for appealing 

decisions about health care payment or services. Whether you have 

Original Medicare or a Medicare Advantage Plan (like an HMO 

or PPO), you have the right to appeal, and to file grievances.

Appeals 

An appeal is the action you can take if you disagree with a coverage 

or payment decision made by Medicare, your Medicare Health 

Plan, or your Medicare Prescription Drug Plan. You can appeal if 

Medicare or your plan denies: 

■ Your request for a health care service, supply, or drug that you 

think you should be able to get 

■ Your request for payment for health care services or supplies or a 

prescription drug you already got 

■ Your request to change the amount you must pay for a 

prescription drug 

You can also appeal if Medicare or your plan stops providing or 

paying for all or part of an item or service you think you still need. 

Appeal rights in Original Medicare 

If you have Original Medicare, you can file an appeal if you aren’t 

satisfied with a coverage or payment decision. If you file an appeal, 

ask your doctor or provider for any information related to the bill 

that might help your case. Your appeal rights are on the back of 

the Medicare Summary Notice (MSN) that is mailed to you from a 

company that handles bills for Medicare. The notice will also tell you 

why Medicare didn’t pay your bill and how you can appeal. Please 

review your Medicare notices carefully and follow the instructions 

before filing an appeal. 

Section 6: Appeals & Grievances 
42 Section 6—Appeals & Grievances 

Appeal rights in a Medicare health plan 

If you’re in a Medicare health plan, or a Medicare Prescription 

Drug Plan, you can file an appeal for any of the reasons listed 

on page 41. For more information on your appeal rights, see 

your plan’s membership materials, contact your plan, or visit 

www.medicare.gov/publications to view the booklet, “Medicare 

Appeals.” You may also call 1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048. 

Filing a grievance (complaint) 

A grievance is different from an appeal. A grievance is for problems 

you have with the way you get services. If you have a problem with 

your ESRD dialysis facility: 

■ Talk with your doctor, nurse, or facility administrator first to see 

if they can help you solve your problem. Most problems can be 

handled at your facility. 

■ File a grievance (a written complaint) with your facility if talking to 

your health care team doesn’t solve the problem. 

Every facility has a grievance policy for accepting and trying to work 

out your problems or concerns. If you don’t know your facility’s 

grievance policy, ask for a copy of it. 

If you filed a grievance with your facility and you still feel that your 

problem has not been solved, you have the right to file a grievance 

with the ESRD Network in your area. See pages 50–51. Call the 

ESRD Network to find out how to file a grievance. You can also call 

your State Survey Agency to complain about your care. Your calls 

and name will be kept private. Visit www.medicare.gov/contacts to 

get the phone number to the State Survey Agency. You can also call 

1-800-MEDICARE. 
43

Words in red

are defined on 

pages 53–54. 

Section 7: Other Kinds of 

Health Insurance 

There are other kinds of health insurance coverage that may help 

pay for the services you need for the treatment of permanent 

kidney failure. They include: 

■ Employee or retiree coverage from an employer or union 

■ Medicare Supplement Insurance (Medigap) policies 

■ Medicaid 

■ Veteran Administration benefits 

Employee or retiree coverage from an employer or union 

If you have group health plan coverage based on your or 

your spouse’s past or current employment, call your benefits 

administrator to find out what coverage they might provide for 

your permanent kidney failure. If you’re eligible for coverage under 

the group health plan, but haven’t yet signed up for it, call the 

benefits administrator to find out if you can still enroll. 

Generally, employer plans have better rates than you can get if you 

buy a policy directly from an insurance company. Also, employers 

may pay part of the cost of the coverage. 

See pages 13–15 for an explanation of when your employer will 

pay first, and when Medicare will pay first with your employer 

providing supplemental coverage. 

If you lose your employer or union coverage, you may be able to 

continue your coverage temporarily through COBRA. This Federal 

law allows you to temporarily keep your employer or union health 

coverage after your employment ends or after you lose coverage 

as a dependent of a covered employee. Talk to your benefits 

administrator for more information. 
44 Section 7—Other Kinds of Health Insurance 

Medicare Supplement Insurance (Medigap) policies 

A Medigap policy is health insurance sold by private insurance companies 

to help fill the “gaps” in Original Medicare coverage, like deductibles and 

coinsurance. Medigap policies help pay some of the health care costs that 

Original Medicare doesn’t cover. Medigap insurance must follow Federal 

and state laws that protect you. All Medigap policies are clearly marked 

“Medicare Supplement Insurance.” 

Not all insurance companies will sell Medigap policies to people with 

Medicare under 65. If a company does sell Medigap policies voluntarily, 

or because state law requires it, these Medigap policies will probably 

cost you more than if you were 65 or older. Medigap rules vary from 

state to state. Call your State Health Insurance Assistance Program (see 

pages 50–51) for information about buying a Medigap policy if you’re 

disabled or have ESRD. When you turn 65, you will be guaranteed an 

opportunity to buy a Medigap policy. 

For detailed information about Medigap policies: 

✓ Visit www.medicare.gov/publications to read or print a copy of 

“Choosing a Medigap Policy: A Guide to Health Insurance for People 

with Medicare.” 

✓ Visit www.medicare.gov/medigap to get information about 

Medigap policies in your state. When you use this Web site, you’ll get 

a personalized summary page with general information to help you 

compare plans. You can get detailed information about all the plans 

available in your area, or just the ones you’re most interested in. This 

Web site has the following information: 

■ Which Medigap policies are sold in your state 

■ Comparing Medigap policies 

■ What each policy covers 

■ Your out-of-pocket costs 

If you don’t have a computer, your local library or senior center may be 

able to help you look at this information. 
Section 7—Other Kinds of Health Insurance 45

Medicaid 

This is a joint Federal and state program that helps pay medical 

costs for some people with limited income and resources. Medicaid 

programs vary from state to state. Most health care costs are 

covered if you qualify for both Medicare and Medicaid and see 

providers who accept both. 

States also have Medicare Savings Programs that pay some or all of 

Medicare’s premiums and may also pay Medicare deductibles and 

coinsurance for certain people who have Medicare and a limited 

income. To qualify for these programs, generally you must have: 

■ Medicare Part A. 

■ A monthly income of less than $1,277 for an individual or $1,723 

for a couple in 2012. These income limits are slightly higher in 

Hawaii and Alaska. Income limits can change each year. 

■ Savings of $6,940 or less for an individual, or $10,410 or less for a 

couple. Savings include money in a checking or savings account, 

stocks, and bonds. 

To get more information on these 

programs, visit www.medicare.gov. 

You can also call 1-800-MEDICARE 

(1-800-633-4227), and ask for information 

on “savings for people with Medicare.” 

TTY users should call 1-877-486-2048. 
46 Section 7—Other Kinds of Health Insurance 

Veterans’ benefits 

If you’re a veteran, the U.S. Department of Veterans Affairs can 

help pay for ESRD treatment. For more information, call the U.S. 

Department of Veterans Affairs at 1-800-827-1000. TTY users should 

call 1-800-829-4833. If you or your spouse is active duty or retired 

from the military, call the Department of Defense at 1-800-538-9552 

for more information. TTY users should call 1-866-363-2883. 

Other ways to get help 

In most states there are agencies and state kidney programs that 

help with some of the health care costs that Medicare doesn’t pay. 

Call your State Health Insurance Assistance Program if you have 

questions about health insurance. See pages 50–51. 
47

Words in red

are defined on 

pages 53–54. 

Section 8: Where to Get More 

Information 

Talk with your health care team to learn more about kidney dialysis, 

transplants, and your situation. 

Kidney organizations 

There are special organizations that can give you more information 

about kidney dialysis and kidney transplants. Some of these 

organizations have members who are on dialysis or have had kidney 

transplants and who can give you support. 

American Association of Kidney Patients 

3505 East Frontage Road, Suite 315 

Tampa, Florida 33607 

1-800-749-2257 

www.aakp.org

American Kidney Fund 

6110 Executive Boulevard, Suite 1010 

Rockville, Maryland 20852 

1-800-638-8299 

www.kidneyfund.org

Dialysis Patient Citizens 

900 7th Street, NW, Suite 670 

Washington, DC 20001 

1-866-877-4242

www.dialysispatients.org

National Kidney Foundation, Inc. 

30 East 33rd Street 

New York, New York 10016 

1-800-622-9010 

www.kidney.org

National Kidney and Urologic Diseases Information Clearinghouse 

3 Information Way 

Bethesda, Maryland 20892 

1-800-891-5390 

www.kidney.niddk.nih.gov
48 Section 8—Where to Get More Information 

End-Stage Renal Disease (ESRD) Networks 

You can call your local ESRD Network Organization (see pages 50–51) 

to get information about the following: 

■ Dialysis or kidney transplants 

■ How to get help from other kidney-related agencies 

■ Problems with your facility that aren’t solved after talking to 

facility staff 

■ Location of dialysis facilities and transplant centers 

Your ESRD Network makes sure that you’re getting the best possible 

care and keeps your facility aware of important issues about kidney 

dialysis and transplants. 

State Health Insurance Assistance Programs (SHIP) 

Call your State Health Insurance Assistance Program (see pages 50–51) 

if you have questions about: 

■ Medigap policies 

■ Medicare health plan choices 

■ Filing an appeal 

■ Other general health insurance questions 

State Survey Agency 

The State Survey Agency inspects dialysis facilities and makes sure that 

Medicare standards are met. Your State Survey Agency can also help 

you if you have a complaint about your care. Visit 

www.medicare.gov/contacts to get the phone number of your State 

Survey Agency. You can also call 1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048. Your calls and name will be 

kept private.
Section 8—Where to Get More Information 49

Other Medicare products for kidney patients 

To read or print a copy of these booklets, visit 

www.medicare.gov/publications. You can also call 

1-800-MEDICARE (1-800-633-4227) to find out if a copy can be 

mailed to you. TTY users should call 1-877-486-2048. 

1. “Dialysis Facility Compare” 

This brochure gives you information about the Dialysis 

Facility Compare tool at www.medicare.gov/dialysis. 

2. “Medicare’s Coverage of Dialysis and Kidney Transplant 

Benefits: Getting Started” 

This brochure explains basic Medicare benefits for people 

with kidney disease. 

3. “Medicare for Children with End-Stage Renal Disease” 

This brochure gives information about Medicare coverage 

for children with permanent kidney failure. 

Important phone numbers 

ESRD Networks and State Health Insurance Assistance Program 

phone numbers are on pages 50–51. At the time of printing, these 

phone numbers were correct. Phone numbers sometimes change. 

To get the most updated phone numbers, visit 

www.medicare.gov/contacts. You can also call 1-800-MEDICARE. 
50 Section 8—Where to Get More Information 

This page has been intentionally left blank. The printed version contains phone 

number information. For the most recent phone number information, please 

visit www.medicare.gov/contacts. Thank you. 
Section 8—Where to Get More Information 51

This page has been intentionally left blank. The printed version contains phone 

number information. For the most recent phone number information, please 

visit www.medicare.gov/contacts. Thank you. 
52 Section 8—Where to Get More Information 

Important phone numbers 

Phone number 

Doctor 

Social worker 

Health insurance company 

ESRD Network 

State Survey Agency 

Notes
53

Section 9: Definitions 

Assignment—An agreement by your doctor or other supplier to be paid 

directly by Medicare, to accept the payment amount Medicare approves 

for the service, and not to bill you for any more than the Medicare 

deductible and coinsurance. 

Benefit period—The way that Original Medicare measures your use 

of hospital and skilled nursing facility (SNF) services. A benefit period 

begins the day you go into a hospital or skilled nursing facility. The 

benefit period ends when you haven’t received any inpatient hospital care 

(or skilled care in a SNF) for 60 days in a row. If you go into a hospital or 

a skilled nursing facility after one benefit period has ended, a new benefit 

period begins. You must pay the inpatient hospital deductible for each 

benefit period. There is no limit to the number of benefit periods. 

Coinsurance—An amount you may be required to pay as your share of 

the cost for services after you pay any deductibles. Coinsurance is usually 

a percentage (for example, 20%). 

Copayment—An amount you may be required to pay as your share 

of the cost for a medical service or supply, like a doctor’s visit, hospital 

outpatient visit, or a prescription. A copayment is usually a set amount, 

rather than a percentage. For example, you might pay $10 or $20 for a 

doctor’s visit or prescription. 

Deductible—The amount you must pay for health care or prescriptions, 

before Original Medicare, your prescription drug plan, or your other 

insurance begins to pay. 

End-Stage Renal Disease (ESRD)—Permanent kidney failure that 

requires a regular course of dialysis or a kidney transplant. 

Grievance—A complaint about the way your Medicare Health Plan or 

Medicare drug plan is giving care. For example, you may file a grievance 

if you have a problem calling the plan or if you’re unhappy with the way a 

staff person at the plan has behaved towards you. However, if you have a 

complaint about a plan’s refusal to cover a service, supply, or prescription, 

you file an appeal. 
54 Section 9—Definitions 

Medically necessary—Services or supplies that are needed for the 

diagnosis or treatment of your medical condition and meet accepted 

standards of medical practice. 

Medicare Advantage Plan (Part C)—A type of Medicare health plan 

offered by a private company that contracts with Medicare to provide 

you with all your Medicare Part A and Part B benefits. Medicare 

Advantage Plans include Health Maintenance Organizations, 

Preferred Provider Organizations, Private Fee-for-Service Plans, 

Special Needs Plans, and Medicare Medical Savings Account Plans. 

If you’re enrolled in a Medicare Advantage Plan, Medicare services are 

covered through the plan and aren’t paid for under Original Medicare. 

Most Medicare Advantage Plans offer prescription drug coverage. 

Medicare-approved amount—In Original Medicare, this is the 

amount a doctor or supplier that accepts assignment can be paid. 

It includes what Medicare pays and any deductible, coinsurance, 

or copayment that you pay. It may be less than the actual amount a 

doctor or supplier charges. 

Medicare health plan—A Medicare health plan is offered by a 

private company that contracts with Medicare to provide Part A and 

Part B benefits to people with Medicare who enroll in the plan. This 

term includes all Medicare Advantage Plans, Medicare Cost Plans, 

Demonstration/Pilot Programs, and Programs of All-inclusive Care 

for the Elderly (PACE). 

Original Medicare—Original Medicare is fee-for-service coverage 

under which the government pays your health care providers directly 

for your Part A and/or Part B benefits. 

Premium—The periodic payment to Medicare, an insurance company, 

or a health care plan for health or prescription drug coverage. 

Secondary payer—The insurance policy, plan, or program that pays 

second on a claim for medical care. This could be Medicare, Medicaid, 

or other insurance depending on the situation. 
55

Index 

A 

American Association of Kidney Patients 47 

American Kidney Fund 47

Appeals 41–42, 48

Assignment 34, 53

B 

Benefit Period 33, 53

Blood Coverage 19, 29–30, 35–36

C 

Children 16, 21, 49

Coinsurance 9, 15, 21–23, 33–34, 38, 44–45, 53

D 

Deductible 9, 15, 22–23, 33–35, 38, 44–45, 53

Definitions 53–54

Dialysis 6–8, 11–14, 17–27

Finding a dialysis facility 24

Travel 26

What’s covered 18

What’s not covered 19

Dialysis Patient Citizens 47

E 

Employer Group Health Plan 11, 13–15, 43

Enrollment (Medicare) 10

ESRD Networks 24, 42, 48, 50–51

Extra Help 37–38

G 

Grievance (Complaints) 24, 29, 42, 53

H 

HMO 9–10

Home Dialysis Treatment 11, 18–19, 22–24

Training 11, 13, 18–20

I 

Immunosuppressive Drugs 14, 30–32, 37

K 

Kidney Organizations 47

Kidney Transplant 7, 29–34

Drugs 14, 30–32

What’s covered 30

What you pay 33

M 

Medicaid 45

Medicare Advantage Plans 9–10, 26, 54

Medicare Coverage (Begins) 11–12

Medicare Coverage (Ends) 12

Medigap Policies 44

N 

National Kidney and Urologic Diseases 

Information Clearinghouse 47

National Kidney Foundation, Inc. 47

O 

Original Medicare 6, 9–10, 21–23, 

33–34, 37, 41–42, 44, 54

P 

Pancreas Transplant 32

Part A (Hospital Insurance) 7–10, 12, 

14–15, 18, 30, 35, 45

Part B (Medical Insurance) 7–10, 12, 

14–15, 18, 20–23, 30, 34–35, 37

Phone Numbers for Help 47, 49–51

Premium 7–8, 10, 15, 21, 37–38, 45, 54

R 

Railroad Retirement 8, 16

S 

Secondary Payer 13, 54

Social Security 7–8, 10, 16, 38

Special Needs Plan 9, 54

State Health Insurance Assistance 

Program (SHIP) 24, 39, 44, 46, 48, 

50–51

T 

This page has been intentionally left 

blank. 51

Travel (Dialysis) 26

V 

Veterans’ Benefits 46
This booklet is available in Spanish. To get your copy, 

call 1-800-MEDICARE (1-800-633-4227). TTY users 

should call 1-877-486-2048. 

Esta publicación está disponible en Español. Para 

obtener una copia, llame al 1-800-MEDICARE 

(1-800-633-4227). Los usuarios de TTY deben llamar 

al 1-877-486-2048. 

U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

7500 Security Boulevard 

Baltimore, Maryland 21244-1850

Official Business 

Penalty for Private Use, $300 

CMS Product No. 10128 

Revised April 2012