Contents
Medicare basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Kidney dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Kidney transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Medicare drug coverage (Part D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Costs & payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Filing a complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
More information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
CMS Accessible communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Nondiscrimination notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Section 1: Medicare basics 1
Section 1
Medicare basics
What’s Medicare?
Medicare is federal health insurance for:
• People 65 and older
• People under 65 with certain disabilities
• People with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring
dialysis or a kidney transplant)
Words in blue are
defined on page 45.
Section 1: Medicare basics2
What does Medicare cover?
Medicare Part A (Hospital Insurance) helps cover:
• Inpatient care in hospitals
• Skilled nursing facility 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
• Durable medical equipment (like wheelchairs, walkers, hospital beds, and other
equipment)
• Many preventive services (like screenings, shots or vaccines, and yearly “Wellness”
visits)
Medicare Part D (Drug coverage)
Helps cover the cost of prescription drugs (including many recommended shots or
vaccines). Part D also helps you with the costs of your drugs not covered by Part B.
Plans that oer Medicare drug coverage (Part D) are run by private insurance
companies that follow rules set by Medicare. Dierent plans cover dierent drugs,
but plans must cover a wide range of medically necessary drugs that people with
Medicare take.
For more details about what Medicare covers, visit Medicare.gov, or call
1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Medicare plan choices
There are two main ways to get Medicare. You can choose between Original Medicare
or join a Medicare Advantage Plan.
If you have ESRD & choose Original Medicare
You can go to any doctor or supplier that accepts Medicare and is accepting new
patients, or to any participating hospital or other facility.
You pay a set amount for your health care (deductible) before Medicare starts paying.
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 Medicare drug coverage
(Part D) by joining a Medicare drug plan. Go to page 25.
Section 1: Medicare basics 3
Medicare plan choices (continued)
If you have ESRD & choose a Medicare Advantage Plan
Medicare Advantage Plans are a type of Medicare health plan oered by a private
insurance company that contracts with Medicare to give all of your Part A and Part B
benefits. Most Medicare Advantage Plans also oer Part D drug coverage. Medicare
Advantage Plans must cover all of the services that Original Medicare covers. Some
plans may oer extra benefits that Original Medicare doesn’t cover, like vision,
hearing, and dental services. Out-of-pocket costs vary in each plan.
Once you have Medicare Part A and Part B, you can join a Medicare Advantage Plan.
Visit Medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-
plan to learn more.
Important: In many cases, you can only use health care providers who are in the
plan’s network and service area. Before you join, check with your providers and
the plan you’re considering to make sure the providers you currently see (like your
dialysis facility or kidney doctor), or want to see in the future (like a transplant
specialist), are in the plan’s network. If you’re already in a Medicare Advantage Plan,
check with your providers to make sure they’ll still be part of the plan’s network next
year. To learn more about a specific Medicare Advantage Plan, contact the plan, or
visit Medicare.gov/plan-compare.
If you join a Medicare Advantage Plan during Open Enrollment
(October 15–December 7), or within the first 3 months you have Medicare
Part A and Part B, you’re eligible to change your enrollment choice. You can also
make changes during the Medicare Advantage Open Enrollment
(Jan 1–March 31). If you have a Medicare Advantage Plan, you can switch back to
Original Medicare or change to a dierent Medicare Advantage Plan (depending on
which coverage works best for you).
To learn more about Medicare Advantage Plans, visit Medicare.gov/health-drug-
plans/health-plans/your-coverage-options/compare.
For more information about your Medicare plan choices, look at the most recent
“Medicare & You” handbook or visit Medicare.gov. You can also call 1-800-MEDICARE
(1-800-633-4227) to get more information. TTY users can call 1-877-486-2048.
Section 1: Medicare basics4
Getting Medicare with ESRD
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 one of these applies to you:
• You’ve worked the required amount of time under Social Security, the Railroad
Retirement Board (RRB), or as a government employee
• You’re already getting or are eligible for Social Security or RRB benefits
• You’re the spouse or dependent child of a person who meets either of the
requirements above
You must also file an application and meet any waiting periods that
apply.
Note: If you qualify for Medicare Part A, you can also get Medicare Part B. Most people
must pay a monthly premium for Part B. Go to page 29. Signing up for 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. Go to page 39.
Visit SSA.gov or call Social Security at 1-800-772-1213 for more information about the
required amount of time needed under Social Security, the RRB, or as a government
employee to be eligible for Medicare based on ESRD. TTY users can call
1-800-325-0778.
If your child has ESRD
Your child can be covered if you or your spouse has worked the required amount of
time under Social Security, the RRB, or as a government employee. Your child can also
be covered if you, your spouse, or your child gets Social Security or RRB benefits, or is
eligible to get those benefits.
Medicare can help cover your child’s medical costs if your child needs regular dialysis
because their kidneys no longer work, or if they had a kidney transplant.
Visit Medicare.gov/basics/children-and-end-stage-renal-disease for more information.
To sign your child up for Medicare, or to get more information about eligibility, call or
visit your local Social Security oce. You can call Social Security at 1-800-772-1213 to
make an appointment. TTY users can call 1-800-325-0778.
Section 1: Medicare basics 5
How to sign up for Medicare
If you’re eligible for Medicare because of ESRD, you can sign up by visiting your local
Social Security oce or calling Social Security at 1-800-772-1213. TTY users can call
1-800-325-0778.
Once you have Medicare, you’ll need to choose how you get your coverage. Go to
pages 2–4. For more information on your coverage options, visit Medicare.gov.
Note: If you already have Medicare because of age or disability, and you’re currently
paying a Part B late enrollment penalty, you'll need to sign up again for Medicare
(because of ESRD) to stop paying the penalty. Call your local Social Security oce to
make an appointment to re-enroll in Medicare based on ESRD.
When Medicare coverage begins
Eligibility for Medicare coverage because of ESRD works dierently than other types
of Medicare eligibility. If you’re eligible for Medicare because of ESRD and don’t sign
up right away, your coverage could be retroactive up to 12 months before the month
you apply, but no earlier than the date you first became eligible. Retroactive coverage
means you may be covered for some costs that occurred in the past.
Example: If you become eligible for Medicare based on ESRD in February, but don’t
sign up for Medicare until November, your Medicare coverage will backdate to
February.
For more information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
TTY users can call 1-877-486-2048.
If you’re on dialysis
When you sign up for Medicare because of ESRD and you’re on dialysis, Medicare
coverage usually starts on the first day of the fourth month of your continuous
dialysis treatments (also known as a “waiting period”). For example, if you start
dialysis on July 1, your coverage will begin 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.
Section 1: Medicare basics6
When Medicare coverage begins (continued)
For some, Medicare coverage can begin as early as the first month of a regular
course of dialysis treatments if you meet both of these conditions:
• You participate in a home dialysis training program oered by a Medicare-certified
training facility during the first 3 months of your regular course of dialysis
• Your doctor expects you to finish training and be able to do your own dialysis
treatments
Important: Medicare won’t cover surgery or other services needed to prepare for
dialysis (like surgery for 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.
If you’re already getting Medicare due to age or disability, Medicare will cover
physician-ordered fistula placement or other preparatory services before dialysis
begins.
If you’re getting a kidney transplant
Medicare coverage can begin the month you’re admitted to a Medicare-certified
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 next 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, after his hospital admission, his Medicare coverage will still begin in
March.
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), Medicare coverage can begin 2 months before your transplant.
Section 1: Medicare basics 7
When Medicare coverage ends
If you’re eligible for Medicare only because of ESRD 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 resume 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
Note: Medicare oers a benefit that helps pay for immunosuppressive drugs beyond
36 months, if you don’t have certain types of health coverage. This benefit only
covers immunosuppressive drugs and no other items or services. It isn’t a substitute
for full health coverage. Visit Medicare.gov/basics/end-stage-renal-disease to learn
more.
How Medicare works with employer or union group health
plan coverage
If you’re eligible for Medicare only because of permanent kidney failure, your
coverage usually can’t start until after the waiting period. This means if you have
coverage through an employer or union group health plan, that plan will be the only
payer for your first 3 months of dialysis (unless you have other coverage).
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. Go to
pages 39–41.
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.
If your plan doesn’t pay 100% of your health care bills, Medicare may pay some of
the remaining costs during a coordination period. 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 (the insurance policy, plan, or program
that pays second on a claim for medical care). This coordination period lasts for 30
months.
Section 1: Medicare basics8
The 30-month coordination period
The 30-month coordination period 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.
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 participate in home 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 right away. This is very important to make sure that your services are
billed correctly. 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 Medicare doesn't cover. Check with your plan’s
benefits administrator for more information.
There’s a separate 30-month coordination period each time you sign up for 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 based on your age or disability).
If after 36 months you sign up for 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.
Section 1: Medicare basics 9
Do I have to get Medicare if I already have an employer or union
group health plan?
No, but 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. Medicare Part B only covers immunosuppressive drugs in specific
circumstances. Go to pages 21–23.
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 Part D drug coverage plan. Turn
to pages 25–28 to learn more.
If your group health plan coverage has a yearly deductible, copayment, or
coinsurance, signing up for Medicare 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 (like if it doesn’t have a yearly deductible), you may
choose to delay signing up for Part A and Part B until the 30-month coordination
period is over.
If you delay enrollment in Medicare, 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
sign up for Part A and Part B. Your Part B premium won’t be higher because you
delayed your enrollment while you’re covered under employer or union group health
plan based on your or your spouse’s current employment. If your group health plan
benefits are decreased or end during the coordination period, you should sign up for
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.
Section 1: Medicare basics10
NOTES
Section 2: Kidney dialysis 11
Section 2
Kidney dialysis
What’s 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. Dialysis also
helps control blood pressure and helps your body keep the right amount of fluids.
Dialysis treatments may help you feel better and live longer, but they aren’t a cure for
permanent kidney failure.
Words in blue are
defined on page 45.
Section 2: Kidney dialysis12
Dialysis treatment options
There are 2 types of dialysis treatment options:
• 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 dialyzer to clean out wastes and extra fluids. Then, the newly-cleaned
blood flows through another set of tubes back into your body. Hemodialysis
treatment can happen at a dialysis facility or at home.
• Peritoneal dialysis uses a special solution (called dialysate) that flows through a
tube into your abdomen. After a few hours, the dialysate takes 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 which type of dialysis you
need based on your situation.
Section 2: Kidney dialysis 13
Dialysis services & supplies covered by Medicare
Service or supply
Medicare
Part A
Medicare
Part B
Inpatient dialysis treatments (if you’re
admitted to a hospital for special care).
✓
Outpatient dialysis treatments and doctors’
services
(in a Medicare-certified dialysis
facility or your home). Go to pages 14–17.
✓
Home 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). Go to
pages 16–17.
✓
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). Go to pages 16–17.
✓
Most drugs for outpatient or home dialysis. Go
to page 25.
✓
Other services and supplies that are part of
dialysis
(like laboratory tests).
✓
To find out what you pay for these services, go to pages 29–34.
Section 2: Kidney dialysis14
Dialysis services & supplies NOT covered by Medicare
Medicare doesn’t cover these services or supplies:
• Paid dialysis aides that help you with home dialysis
• Any lost pay to you or the person who may be helping you during home dialysis
training
• A place to stay during your treatment
• Blood or packed red blood cells for home dialysis, unless part of a doctor’s service
There are some types of coverage that may pay some of the health care costs that
Medicare doesn’t pay. Go to pages 39–41. For more information on Medicare drug
coverage (Part D), go to pages 25–28.
Dialysis facilities
Dialysis can be done at home or in a Medicare-certified dialysis facility (also known
as a dialysis center). For Medicare to pay for your treatments, the facility must be
Medicare-certified to give dialysis, even if the facility already gives 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 ask a family member or friend for help with your
treatment.
Medicare evaluates dialysis facilities each year using dierent quality measures. These
quality measures show how often dialysis facilities use best practices when caring
for you. Medicare gives each dialysis facility a score based on its evaluation of these
quality measures. Dialysis facilities are required to display that score in an area that’s
easy for you to find, and in a format and language you understand.
How to find a facility
In most cases, you’ll get your dialysis treatments at the facility where your kidney
doctor works. You have the right to choose to get your treatments from another
facility at any time, but this could mean changing doctors.
You can visit Medicare.gov/care-compare to find a dialysis facility that’s close to you,
or call your local ESRD Network (go to page 35).
Medicare.gov/care-compare has detailed information about Medicare-certified
dialysis facilities. You can compare dialysis facilities based on their star ratings, as well
as the services and quality of care they give. It also has other resources for patients
and family members who want to learn more about chronic kidney disease and
dialysis.
Section 2: Kidney dialysis 15
How to find a facility (continued)
When you visit Medicare.gov/care-compare, you can find and compare this
information about dialysis facilities:
• Addresses
• Phone numbers
• Maps and directions
• Types of dialysis services oered
• Quality of patient care information
• Patient experience of care survey results
If you don’t have a smart phone or computer, your local library or senior center may
be able to help you look up information on dialysis facilities. You can also contact
your local State Health Insurance Assistance Program (SHIP) (go to page 44), or call
1-800-MEDICARE (1-800-633-4227) to get help comparing dialysis facilities. TTY
users can call 1-877-486-2048.
If you have a problem finding a dialysis facility that’s willing to take you as a patient,
you have the right to file a complaint (grievance). Go to pages 35–37.
Transportation to dialysis facilities
Original Medicare only covers ambulance services to and from your home to the
nearest dialysis facility, when other forms of transportation could endanger 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 facilities and doctors. Read your plan materials, or call the
plan for more information.
For more information about ambulance coverage, visit Medicare.gov/coverage/
ambulance-services. You can also call 1-800-MEDICARE (1-800-633-4227).
If you need help with non-ambulance transportation, talk to the social worker at your
dialysis facility to find out your options.
Section 2: Kidney dialysis16
Dialysis in a hospital
If you’re admitted to a hospital and get dialysis, Medicare Part A will cover your
treatments as part of the cost of your covered inpatient hospital stay.
Go to page 32.
Home dialysis
Medicare Part B covers training for home dialysis, but only by a facility certified for
dialysis training. You may qualify for training if you think you'll benefit from home
dialysis treatments, and your doctor approves. Training sessions occur at the same
time you get dialysis treatment and are limited to a maximum number of sessions.
Your dialysis facility is responsible for providing all of your home dialysis related items
and services, including equipment and supplies, that are medically necessary and
reasonable.
Your dialysis facility must give you these items and services directly, or through an
arrangement with another provider.
Medicare makes a single payment per dialysis treatment to the dialysis facility for
all dialysis-related services, including equipment and supplies. Dialysis facilities pay
third-party suppliers from this single payment amount.
Monthly doctor visits for home dialysis
You may be able to get a monthly visit from your doctor (or certain other health care
providers, like physician assistants and nurse practitioners) to help you manage your
care.
This benefit includes an in-person visit between you and your health care provider
once a month. You can also choose to get some of your monthly visits via telehealth.
These visits allow you and your doctor to review your lab work, discuss your care and
the eectiveness of your dialysis, check for complications, and give you a chance to
ask questions about your home dialysis treatment. To learn more about telehealth,
visit Medicare.gov/coverage/telehealth.
Section 2: Kidney dialysis 17
Home dialysis (continued)
Dialysis when you travel
You can still travel within the U.S. if you need dialysis. There are about 6,000 dialysis
facilities around the country. Your facility can help you plan your treatment along the
route of your trip before you travel.
While you’re traveling, you may need to pay your copayment when you get your
dialysis. Check with the social worker at your home dialysis facility to learn more.
Your dialysis facility will help you by checking to see if the facilities on your route:
• Are Medicare-certified 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 U.S.
Note: If you get your dialysis services from a Medicare Advantage Plan, your plan may
be able to help you arrange dialysis treatment while you travel. Contact your plan for
more information.
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, 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.
The minimum numbers for adequate dialysis dier based on the type of dialysis
(hemodialysis or peritoneal dialysis) treatment you’re getting. 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, which can lead
to a higher risk of infection and prolonged bleeding, and shorten your life.
Section 2: Kidney dialysis18
Knowing how well your dialysis is working (continued)
Here are some steps you can take to help make dialysis work better:
• Arrive on time to all of your scheduled treatments.
• Stay for the full treatment time.
• Follow your diet and fluid restrictions.
• Follow the advice of your dialysis sta on taking care of yourself.
• Check your URR or Kt/V adequacy number each month.
• Before you start dialysis, talk to your doctor about which hemodialysis vascular
access is best for you. Your vascular access uses your blood vessels and is created
by a surgeon to use for cleaning your blood during dialysis. During dialysis, your
blood is removed and returned through your vascular access.
• Learn how to care for 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. If you have a problem with the care that
you’re getting for your kidney disease, you have the right to file a complaint. Go to
pages 35–37.
Section 3: Kidney transplants 19
Section 3
Kidney transplants
What’s a kidney transplant?
A kidney transplant is a type of surgery that puts someone else’s healthy kidney into
your body. This donated kidney does the work that your own kidneys no longer do.
You may get a kidney from someone who has recently died, or from someone who’s still
living, like an eligible family member. The blood of the possible kidney donor must be
tested to make sure that it’s compatible with your body so that your body won’t reject
the new kidney.
Original Medicare will cover your kidney transplant only if it’s done in a hospital that’s
Medicare-certified to do kidney transplants. If you’re in a Medicare Advantage Plan, you
might be able to use hospitals outside the plan’s network and service area. Check with
your plan to see which hospital you can use.
If you have a problem with the care that you’re getting for your transplant or with
getting a referral for a transplant work-up, you have the right to file a complaint. Go to
pages 35–37.
Section 3: Kidney transplants20
Kidney transplant services covered by Medicare
Service or supply
Medicare
Part A
Medicare
Part B
Inpatient services in a Medicare-certified hospital.
✓
Kidney registry fee.
✓
Laboratory and other tests to evaluate your medical
condition and the condition of potential kidney
donors. Medicare covers these services at Medicare-
certified hospitals where you’ll get your transplant,
or another hospital that participates in Medicare.
✓
The costs of finding the proper kidney for your
transplant surgery
(if there’s no kidney donor).
✓
The cost of some care for your kidney donor.
✓
Any extra inpatient hospital care your donor needs
if they experience problems after donation.
✓ ✓
Doctors’ services for kidney transplant surgery
(including care before, during, and after the
surgery).
✓
Doctors’ services for your kidney donor during their
hospital stay.
✓
Transplant drugs (also called immunosuppressive
drugs) for a limited time after you leave the
hospital, following a transplant. Go to pages
21–23.
✓
Blood (whole or units of packed red blood cells,
blood components, and the cost of processing
and giving you blood). Go to page 34.
✓ ✓
To find out what you pay for these services, go to pages 29–34.
Section 3: Kidney transplants 21
ESRD & pancreas transplants
If you have ESRD and need a pancreas transplant, Medicare covers the transplant
if it’s done at the same time you get a kidney transplant or 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 have Medicare only because of permanent kidney failure, and you have
a pancreas transplant after a kidney transplant, Medicare will only pay for your
immunosuppressive drugs for 36 months after the month of the kidney transplant
and your Medicare coverage will end after then. However, you may be eligible for a
Part B benefit that helps continue to pay for your immunosuppressive drugs beyond
36 months. Go to page 22 to learn more.
If you were already eligible for 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 transplant drugs with no time
limit.
Transplant drugs (also called immunosuppressive drugs)
What are transplant drugs?
Transplant drugs are immunosuppressive 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.
If you’re only eligible for Medicare because of ESRD (you aren't 65 or older or have
a disability), Medicare Part B will only cover your transplant drugs if both of these
conditions are met:
• You already had Medicare Part A at the time of your transplant.
• You had transplant surgery at a Medicare-certified facility.
Part B will only cover your transplant drugs after you have Part B. There won’t be any
retroactive coverage (go to page 5).
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. Talk to your doctor before you stop taking your
transplant drugs.
Section 3: Kidney transplants22
Transplant drugs (also called immunosuppressive drugs)
(continued)
How long will Medicare pay for transplant drugs?
If you’re eligible for Medicare only because of ESRD, your Medicare coverage will end
36 months after the month of the transplant.
However, if you're eligible for the Part B immunosuppressive drug benefit, Medicare
will continue to pay for your transplant drugs beyond 36 months. Medicare will pay
without a time limit if one of these conditions applies:
• You were already eligible for Medicare because of age or disability before you got
ESRD.
• You became eligible for Medicare because of age or disability after getting a
transplant that Medicare paid for (in a Medicare-certified facility), or you had
private insurance that paid for your health care before your Medicare Part A
coverage.
What's the immunosuppressive drug benefit?
Medicare oers a benefit that helps you pay for your immunosuppressive drugs
beyond 36 months, if you don’t have or expect to get certain types of other
health coverage (like a group health plan, TRICARE, or Medicaid that covers
immunosuppressive drugs). This benefit only covers your immunosuppressive drugs
and no other items or services. It isn’t a substitute for full health coverage. You can
sign up at any time as long as you had Medicare because of ESRD at the time of your
kidney transplant. To sign up, call Social Security at 1-877-465-0355. This is a special
phone number just for this benefit. TTY users can call 1-800-325-0788.
If you sign up for this benefit, you’ll pay a monthly premium and an annual deductible:
• The monthly premium for this benefit is $103 in 2024. (You may pay a higher
premium based on your income.)
• The annual deductible is $240 in 2024. Once you’ve met the deductible, you’ll pay
20% of the Medicare-approved amount for your immunosuppressive drugs.
You may be able to get help paying for this benefit from programs oered through
your state. Find out how to apply at Medicaid.gov/about-us/beneficiary-resources/
index.html.
Visit Medicare.gov/basics/end-stage-renal-disease to learn more about the Part B
immunosuppressive drug benefit.
Section 3: Kidney transplants 23
Transplant drugs (also called immunosuppressive drugs)
(continued)
What if I can’t pay for the transplant drugs?
If you don't qualify for the Part B immunosuppressive drug benefit and you’re worried
about paying for your transplant drugs 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. Go to pages 39–41.
Section 3: Kidney transplants24
NOTES
Section 4: Medicare drug coverage (Part D) 25
Section 4
Medicare drug coverage
(Part D)
What Medicare covers
Medicare Part B covers transplant drugs after a covered transplant (go to pages 21–23)
and most of the drugs you get for dialysis. However, Part B doesn’t cover drugs for
other health conditions you may have, like high blood pressure. Medicare drug coverage
(Part D) oers drug coverage to help you with the costs of your drugs that
Part B doesn’t cover.
Words in blue are
defined on page 45.
Section 4: Medicare drug coverage (Part D)26
What Medicare covers (continued)
Medicare drug coverage won’t cover drugs you can get under Part B, like
immunosuppressive drugs under the conditions discussed on pages 30–31. However,
if you don’t meet the conditions on pages 30–31, you may be able to get coverage of
your immunosuppressive drugs by joining a Medicare Part D drug plan.
Private companies approved by Medicare oer Part D drug coverage. There are 2
ways to get Medicare drug coverage (Part D):
• Medicare drug plans that add coverage to Original Medicare or certain types of
Medicare health plans.
• Medicare Advantage Plans with drug coverage. You must have Medicare Part A
and Part B to join a Medicare Advantage Plan. Visit Medicare.gov/basics/get-
started-with-medicare/get-more-coverage/joining-a-plan to learn more.
Note: If you join a Medicare Advantage Plan with drug coverage, you'll get your drug
coverage through your plan, and you can't join a separate Medicare drug plan.
Most drug plans charge a monthly premium that varies by plan. You pay this and
the Part B premium. If you’re in a Medicare Advantage Plan with drug coverage, the
monthly premium may include an amount for drug coverage. Your costs will vary
depending on which drugs you use and which drug plan you choose.
When can I join Medicare drug coverage (Part D)?
If you become eligible for Medicare because of ESRD, your first chance to join
Medicare drug coverage (Part D) will be during the 7-month period that begins 3
months before the month you’re eligible for Medicare and ends 3 months after the
first month you’re eligible for Medicare (called your Initial Enrollment Period).
Your Medicare drug coverage will start the same time your Medicare Part A and/or
Part B coverage starts. If you join a Medicare drug plan after your Medicare Part A
and/or Part B coverage starts, it will be eective the first day of the month after you
join. Go to pages 9–10.
If you don’t join when you’re first eligible, or during a Special Enrollment Period, you can
join during Open Enrollment (October 15–December 7 each year). Your coverage will
begin on January 1 of the next 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
Part D or creditable prescription drug coverage, you may have to pay a late enrollment
penalty (which is added to your monthly premium).
Section 4: Medicare drug coverage (Part D) 27
When can I join Medicare drug coverage (Part D)? (continued)
This amount increases the longer you go without Part D or creditable coverage. You’ll
have to pay this penalty as long as you have Medicare drug coverage. However, if you
get Extra Help, you don’t have to pay a late enrollment penalty.
Visit Medicare.gov/drug-coverage-part-d for more information about Medicare drug
coverage. You can also visit shiphelp.org to contact your local State Health Insurance
Assistance Program (SHIP).
Extra Help
Extra Help is a program that helps people with limited income and resources pay
Medicare Part D drug costs. If you qualify, you’ll get help paying for your Medicare
drug plan’s monthly premium, yearly deductible, and prescription copayments or
coinsurance.
In general, to qualify for Extra Help, your yearly income in 2023 must be below
$21,870 ($29,580 for a married couple), and your resources must be below $16,600
($33,240 for a married couple). These amounts may change in 2024.
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 include things like your savings and stocks (but not home), one car,
household items, burial plot, up to $1,500 for burial expenses (per person), and life
insurance policies.
Note: If you live in Puerto Rico, the Virgin Islands, Guam, the Northern Mariana
Islands, or American Samoa, you’re not eligible for the same Extra Help described
here. Visit Medicaid.gov/about-us/beneficiary-resources/index.html#statemenu to
get the contact information for your Medicaid oce.
How can I apply?
Some people with Medicare automatically qualify for Extra Help and will get a letter
from Medicare. Others will need to apply.
If you don’t get a letter stating that you automatically qualify, visit SSA.gov/extrahelp
or call Social Security at 1-800-772-1213 to apply. TTY users can call 1-800-325-0778.
After you apply, you’ll get a letter in the mail letting you know if you qualify and
what to do next. Even if you don’t qualify for Extra Help, you might consider joining a
Medicare drug plan.
Section 5: Costs & payments28
How can I apply? (continued)
If you qualify for Extra Help, and don’t join a Medicare drug plan, Medicare will
automatically enroll you in a plan. You can “opt out” of being automatically enrolled.
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 being enrolled in covers
the drugs you use, and if you can go to the pharmacies you want. If not, you can
change plans. People who qualify for Extra Help can join, switch, or drop a Medicare
drug plan at any time.
Section 5: Costs & payments30
What does Medicare cost? (continued)
Medicare Part B (Medical Insurance) costs
Most people must pay a monthly premium for Part B. The standard
Part B premium for 2024 is $174.70 per month, although it may be higher based on
your income. Premium rates can change yearly.
You need Part B to get full ESRD benefits, including regular dialysis, and you must
pay the Part B premium. For more information about the Part B premium, visit SSA.
gov, or call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.
Note: If you choose to enroll in a Medicare Advantage Plan, you may have dierent or
additional costs based on your plan. For more information on costs, contact your plan
for specific costs information.
What does Medicare pay for dialysis services?
Medicare pays your dialysis facility to give you these Part B-covered dialysis services
and items:
• Direct nursing services including: registered nurses, licensed practical nurses,
technicians, social workers, and dietitians
• All equipment and supplies used for kidney dialysis in the facility, or in your home,
that are reasonable and medically necessary
• Injectable, intravenous (IV), and certain oral drugs that treat or manage conditions
associated with ESRD (like anemia) or are used in the treatment of ESRD
• Laboratory tests
• Home dialysis training by a Medicare-certified home dialysis training facility (if you
choose to get dialysis at home)
• Other items and services, like heart monitoring during your dialysis treatments,
oxygen given (if needed) during your dialysis treatments (if you’re in a dialysis
facility), monitoring of your access site, and certain nutritional services
Your dialysis facility must give you these items and services directly, or through an
arrangement with another provider.
Section 5: Costs & payments 31
What does Medicare pay for dialysis services? (continued)
Important note for people taking Calcimimetics (Sensipar® or
Parsabiv™):
Medicare Part B covers calcimimetic medications under the ESRD payment system.
Calcimimetic medications include the intravenous medication Parsabiv, and the oral
medication Sensipar. Generic versions of Sensipar are available. In addition to the
calcimimetics, both the KORSUVA™ (difelikefalin) injection for the treatment of pruritis
(itching) and JESDUVROQ (daprodustat) tablets, for oral use, for the treatment of
anemia, are available.
Your dialysis facility is responsible for giving you these medications. They can give
them to you at their facility, or through a pharmacy they work with. You’ll have a 20%
coinsurance for these medications. If you’re in a Medicare Advantage Plan, your costs
and coverage for you and your living donors will be (or are) dierent and plan-specific.
You’ll need to work with your dialysis facility and your doctor to find out where you’ll get
these medications, and how much you’ll pay.
Medicare drug coverage (Part D) covers certain medications that are only available
in an oral form. Talk with your doctor or health care team about the use of any drugs,
including over-the-counter products.
What will I pay for dialysis services in a dialysis facility?
If you have Original Medicare, after you pay the Part B yearly deductible, you’ll continue
to pay a 20% coinsurance of the Medicare-approved amount for all covered dialysis-
related services. Medicare will pay the remaining 80%.
The dollar amount of your coinsurance may vary. If you’re in a Medicare Advantage
Plan or have a Medicare Supplement Insurance (Medigap) policy (go to page 40) that
covers all or part of your 20% coinsurance, then your costs may be dierent. Read your
plan materials or call your benefits administrator to get your cost information. You must
also continue to pay your monthly Medicare Part B and Medicare Part D drug coverage
premiums (if applicable).
Note: Your 20% coinsurance covers all of the services and items listed on page 13. Since
the bundled payment system includes these services and items, 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 Part D plan (if you have one).
Section 5: Costs & payments32
What does Medicare pay for dialysis services? (continued)
What will I pay for dialysis in a hospital?
If you’re admitted to a hospital and get dialysis, Part A will cover your treatments as
part of the cost 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
Original Medicare pays most kidney doctors a monthly amount. After you pay
the Part B yearly deductible ($240 in 2024). 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 one month.
Example: 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).
Remember, what you pay may be dierent than what’s shown in this example.
What will I pay for home dialysis training services?
Original Medicare pays your kidney doctor a fee to supervise home dialysis training.
After you pay the Part B yearly deductible ($240 in 2024), Medicare pays 80% of the
fee and you pay the remaining 20%.
Example: Let’s say the fee for the kidney doctor who’s supervising your home 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).
Remember, what you pay may be dierent than what’s shown in this example.
What will I pay for my child who has ESRD?
If you have a child under 18 who has Medicare because of ESRD, the payment rules
are the same as described above. However, the rates paid to dialysis facilities are
increased by 30% and adjusted based on the child’s age and the type of dialysis
they get. These adjustments allow for the special care needs of children. Your 20%
coinsurance will be based on these special rates.
Visit Medicare.gov/basics/children-and-end-stage-renal-disease for more
information on Medicare coverage for children with ESRD.
Section 5: Costs & payments 33
What Medicare pays for transplant services
The amounts listed in this section are for transplant services that Original Medicare
covers. If you’re in a Medicare Advantage Plan, your costs may be dierent. Read
your plan materials, or call your plan to get information about your costs.
What do I have to pay for my kidney donor?
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. Also, your
kidney donor doesn’t have to pay a deductible, coinsurance, or any other costs for
their hospital stay.
What do I have to pay for hospital services?
If you have Original Medicare, in 2024, you pay:
• $1,632 deductible per benefit period
• Days 1–60: $0 coinsurance for each benefit period
• Days 61–90: $408 coinsurance per day of each benefit period
• Days 91 and beyond: $816 coinsurance per each “lifetime reserve day” after day 90
for each benefit period (up to 60 days over your lifetime)
• Beyond lifetime reserve days: all costs
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 you can use
during your lifetime. For each lifetime reserve day, Medicare pays all covered costs
except for a daily coinsurance.
For Medicare-approved care in a skilled nursing facility, you pay:
• Days 1–20: $0 for each benefit period
• Days 21–100: $204 coinsurance per day of each benefit period
• Days 101 and beyond: all costs
To find out what you’ll pay for other Medicare Part A and Medicare Part B services,
visit Medicare.gov/basics/costs, or call 1-800-MEDICARE (1-800-633-4227).
TTY users can call 1-877-486-2048.
What do I have to pay for doctors’ services?
In Original Medicare, you pay the Medicare Part B yearly deductible
($240 in 2024). After you pay the deductible, Medicare pays 80% of the Medicare-
approved amount. You pay the remaining 20% coinsurance.
Section 5: Costs & payments34
What do I have to pay for doctors’ services? (continued)
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’s up to 15% over the Medicare-approved
amount.
What do I have to pay for clinical laboratory services?
You pay nothing for Medicare-approved laboratory tests.
What Medicare pays for blood services
In most cases, Medicare Part A and Medicare Part B help pay for:
• Whole blood units or packed red blood cells
• Blood components
• The cost of processing and giving you blood
What do I pay for blood services?
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.
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’ve 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.
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.
You can’t be charged for blood that you’ve already donated. A hospital or skilled
nursing facility can’t charge you for any of the first 3 pints of blood you’ve already
donated or will donate in the future.
Note: Medicare doesn’t pay for blood as part of home dialysis unless it’s part of a
doctor’s service or is needed to prime the dialysis equipment.
Section 6: Filing a complaint 35
Section 6
Filing a complaint
End-Stage Renal Disease (ESRD) Networks and State Survey Agencies work together
to help you with complaints (grievances) about your dialysis or kidney transplant care.
ESRD Networks
ESRD Networks (or “Networks”) monitor and improve the quality of care
given to people with ESRD, and can help you with complaints about your dialysis
facility or transplant center. Call 1-800-MEDICARE (1-800-633-4227) to get the ESRD
Network phone number for your state. TTY users can call 1-877-486-2048.
Words in blue are
defined on page 45.
Section 6: Filing a complaint36
ESRD Networks (continued)
Call your local ESRD Network to get information about:
• Dialysis treatments
• Kidney transplants
• How to get help from other kidney-related agencies
• Problems with your facility
• Location of dialysis facilities and transplant centers
If you have a complaint about your care:
• You can complain directly to your facility, but you don’t have to.
• You can file it directly with your Network instead of with your facility.
• Your facility or Network must investigate it, work on your behalf to try to solve it,
and help you understand your rights.
• Your Network can still investigate a complaint and represent you, even if you wish
to remain anonymous.
• Your facility can’t take any action against you for filing a complaint.
Examples of complaints you may contact your ESRD Network for
include:
• The facility sta doesn’t treat you with respect.
• The facility sta won’t let you eat during dialysis, and you’re always hungry.
• Your dialysis shifts conflict with your work hours, and the facility won’t let you
change your shift.
• You’ve made complaints to your facility, and they weren’t resolved.
State Survey Agencies
State Survey Agencies inspect Medicare and Medicaid participating 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. Call 1-800-MEDICARE to get
the phone number for your State Survey Agency. Your calls and name will be kept
private.
Examples of complaints you may contact your State Survey Agency for include:
• Claims of abuse
• Mistakes in giving out or prescribing drugs
• Poor quality of care
• Unsafe conditions (like water damage, or electrical or fire safety concerns)
Section 6: Filing a complaint 37
State Survey Agencies (continued)
Note: For questions about a specific service you got, look at your “Medicare
Summary Notice” (MSN) if you have Original Medicare (or similar claim or explanation
of benefit statements from your plan if you’re in a Medicare Advantage Plan). Your
MSN is a notice you get after the doctor, other health care provider, or supplier files a
claim for Part A or Part B services in Original Medicare. It shows:
• All the services or supplies that your providers and suppliers billed to Medicare
during a 3-month period
• What Medicare paid
• The maximum amount you may owe the provider
You’ll get your MSN in the mail every 3 months. You can also create a secure online
Medicare account and sign up for electronic MSNs at Medicare.gov. You’ll get an
email every month when MSNs are available in your Medicare account, instead of
waiting 3 months for a paper copy. If you disagree with a coverage or payment
decision made by Medicare, your Medicare health plan, or your Medicare drug plan,
you can file an appeal. Visit Medicare.gov/claims-appeals/how-do-i-file-an-appeal.
Section 6: Filing a complaint38
NOTES
Section 7: Other health coverage 39
Section 7
Other health coverage
There are other kinds of health coverage that may help pay for the services you need
to treat permanent kidney failure. They include:
• Employee or retiree coverage from an employer or union
• Medicare Supplement Insurance (Medigap)
• Medicaid
• Veterans Administration benefits
Words in blue are
defined on page 45.
Section 7: Other health coverage40
Employee or retiree coverage from an employer or union
If you have coverage from a health plan based on your or your spouse’s past or
current employment, call your benefits administrator to find out what coverage they
might oer for ESRD. 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 those you can get if you buy a policy
directly from an insurance company. Also, employers may pay part of the cost for the
coverage.
Turn to pages 7–9 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. COBRA is a federal law that 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.
Medicare Supplement Insurance (Medigap)
Medigap is health insurance sold by private insurance companies to help fill the
“gaps” in Original Medicare. Medigap policies help pay some of the health care costs
that Original Medicare doesn’t cover, like your deductible or coinsurance. Medigap
must follow federal and state laws that protect you. All Medigap policies are clearly
marked “Medicare Supplement Insurance” and give standardized benefits, no matter
which insurance company sells them.
Not all insurance companies will sell Medigap policies to people under 65 who have
Medicare. If a company does sell Medigap policies voluntarily, or because state law
requires it, these Medigap policies may cost you more than if you were 65 or older.
Medigap rules vary from state to state. Call your State Health Insurance Assistance
Program (SHIP) (go to page 44) for information about buying a Medigap policy if you
have ESRD. When you turn 65, you’ll be guaranteed an opportunity to buy a Medigap
policy.
Visit Medicare.gov/health-drug-plans/medigap to learn more about Medigap and to
compare policies sold in your state.
Section 7: Other health coverage 41
Medicaid
Medicaid 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.
Medicare Savings Programs
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 find out if you qualify for one of these
programs, visit Medicare.gov/medicare-savings-programs.
Veterans’ Administration benefits
If you’re a veteran, the U.S. Department of Veterans Aairs can help pay for ESRD
treatment. For more information, visit va.gov or call the U.S. Department of Veterans
Aairs at 1-800-827-1000. TTY users can call 1-800-829-4833.
Other ways to get help
In most states, there are agencies and programs that help with some of the health care
costs that Medicare doesn’t pay. Call your State Health Insurance Assistance Program
(SHIP) if you have questions about health coverage. Visit shiphelp.org.
Visit Medicare.gov/basics/costs/help, or call 1-800-MEDICARE (1-800-633-4227) to
learn more about getting help with Medicare costs. TTY users can call 1-877-486-2048.
Section 7: Other health coverage42
NOTES
Section 8: More information 43
Section 8
More information
There are many resources available to help you learn more about kidney dialysis,
transplants, and your situation. In addition to talking with your health care team,
you can also connect with other people who have ESRD through national kidney
organizations. Find more information on Medicare.gov, or reach out to your local
ESRD Network, State Health Insurance Assistance Program (SHIP), or State Survey
Agency.
Words in blue are
defined on page 45.
Section 8: More information44
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 can oer you support.
American Association of Kidney Patients
14440 Bruce B. Downs Blvd.
Tampa, Florida 33613
1-800-749-2257
aakp.org
American Kidney Fund
11921 Rockville Pike, Suite 300
Rockville, Maryland 20852
1-800-638-8299
kidneyfund.org
Dialysis Patient Citizens
1001 Connecticut Ave, NW, Suite 1230
Washington DC, 20036
1-866-877-4242
dialysispatients.org
National Institute of Diabetes and Digestive and Kidney Diseases
9000 Rockville Pike
Bethesda, Maryland 20892
1-800-860-8747
niddk.nih.gov
National Kidney Foundation
30 East 33rd Street
New York, New York 10016
1-800-622-9010
kidney.org
State Health Insurance Assistance Programs (SHIPs)
SHIPs are state programs that give free local health insurance counseling to people
with Medicare. Call your SHIP if you have questions about:
• Medigap policies
• Medicare health plan choices
• Filing an appeal
• Other general health insurance questions
Visit shiphelp.org to get the phone number for your SHIP, or call 1-800-MEDICARE (1-
800-633-4227). TTY users can call 1-877-486-2048.
Section 9: Definitions 45
Section 9
Definitions
Assignment—An agreement by your doctor, provider, or 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’re
admitted as an inpatient in a hospital or SNF. The benefit period ends when you
haven’t gotten 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 SNF after one benefit period has ended, a
new benefit period begins. You must pay the inpatient hospital deductible for each
benefit period. There’s no limit to the number of benefit periods.
Section 9: Definitions46
Coinsurance—An amount you may be required to pay as your share of the cost for
benefits 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 benefits after you pay any deductibles. A copayment is a fixed amount, like
$30.
Creditable prescription drug coverage—Prescription drug coverage that’s expected to
pay, on average, at least as much as Medicare drug coverage. This could include drug
coverage from a current or former employer or union, TRICARE, Indian Health Service,
VA, or individual health insurance coverage.
Deductible—The amount you must pay for health care or prescriptions before Original
Medicare, your Medicare Advantage Plan, your Medicare drug plan, or your other
insurance begins to pay.
Home health care—a wide range of health care services that can be given in your
home for an illness or injury.
Medically necessary—Health care services or supplies needed to diagnose or treat an
illness, injury, condition, disease, or its symptoms and that meet accepted standards of
medicine.
Medicare Advantage Plan (Part C)—A type of Medicare health plan oered by a private
company that contracts with Medicare. Medicare Advantage Plans provide all of your
Part A and Part B benefits, with a few exclusions, for example, certain aspects of clinical
trials which are covered by Original Medicare even though you’re still in the plan.
Medicare Advantage Plans include:
• Health Maintenance Organizations
• Preferred Provider Organizations
• Private Fee-for-Service Plans
• Special Needs Plans
• Medicare Medical Savings Account Plans
If you’re enrolled in a Medicare Advantage Plan:
• Most Medicare services are covered through the plan
• Most Medicare services aren’t paid for by Original Medicare
• Most Medicare Advantage Plans oer prescription drug coverage
Section 9: Definitions 47
Medicare-approved amount—The payment amount that Original Medicare sets for a
covered service or item. When your provider accepts assignment, Medicare pays its
share and you pay your share of that amount.
Medicare health plan—Plans oered by private companies that contract with
Medicare to provide Part A, Part B, and in many cases, Part D benefits. Includes
Medicare Advantage Plans and certain other types of coverage (like Medicare Cost
Plans, PACE programs, and demonstration/pilot programs).
Medicare drug coverage (Part D)—Optional benefits for prescription drugs available
to all people with Medicare for an additional charge. This coverage is oered by
insurance companies and other private companies approved by Medicare.
Medicare preventive services—Health care to prevent illness or detect illness at an
early stage, when treatment is likely to work best (for example, preventive services
include Pap tests, flu shots, and screening mammograms).
Original Medicare—A fee-for-service health plan that has 2 parts: Part A (Hospital
Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays
its share of the Medicare-approved amount, and you pay your share (coinsurance and
deductibles).
Penalty—An amount added to your monthly premium for Part B or a Medicare drug
plan (Part D) if you don’t join when you’re first eligible. You pay this higher amount as
long as you have Medicare. There are some exceptions.
Premium—The periodic payment to Medicare, an insurance company, or a health care
plan for health or prescription drug coverage.
Skilled nursing facility (SNF)—A nursing facility with the sta and equipment to give
skilled nursing care and, in most cases, skilled rehabilitative services and other related
health services.
Supplier—Any company, person, or agency that gives you a medical item or service,
except when you’re an inpatient in a hospital or skilled nursing facility.
Accessible communications48
CMS Accessible
communications
Medicare provides free auxiliary aids and services, including information in
accessible formats like braille, large print, data or audio files, relay services and
TTY communications. If you request information in an accessible format, you
won’t be disadvantaged by any additional time necessary to provide it. This
means you’ll get extra time to take any action if there’s a delay in fulfilling your
request.
To request Medicare or Marketplace information in an accessible format you
can:
1. Call us:
For Medicare: 1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
For Marketplace: 1-800-318-2596
TTY: 1-855-889-4325
2. Email us: altformatreques[email protected]
3. Send us a fax: 1-844-530-3676
4. Send us a letter:
Centers for Medicare & Medicaid Services
Oces of Hearings and Inquiries (OHI)
7500 Security Boulevard, Mail Stop DO-01-20
Baltimore, MD 21244-1850
Attn: Customer Accessibility Resource Sta (CARS)
Your request should include your name, phone number, type of information
you need (if known), and the mailing address where we should send the
materials. We may contact you for additional information.
Note: If you’re enrolled in a Medicare Advantage Plan or Medicare drug plan,
contact your plan to request its information in an accessible format. For
Medicaid, contact your State Medical Assistance (Medicaid) oce.
Nondiscrimination Notice
The Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, deny
benefits to, or otherwise discriminate against any person on the basis of race,
color, national origin, disability, sex (including sexual orientation and gender
identity), or age in admission to, participation in, or receipt of the services and
benefits under any of its programs and activities, whether carried out by CMS
directly or through a contractor or any other entity with which CMS arranges
to carry out its programs and activities.
You can contact CMS in any of the ways included in this notice if you have any
concerns about getting information in a format that you can use.
You may also file a complaint if you think you’ve been subjected to
discrimination in a CMS program or activity, including experiencing issues with
getting information in an accessible format from any Medicare Advantage Plan,
Medicare drug plan, state or local Medicaid oce, or Marketplace Qualified
Health Plans. There are 3 ways to file a complaint with the U.S. Department of
Health & Human Services, Oce for Civil Rights:
1. Online:
HHS.gov/civil-rights/filing-a-complaint/complaint-process/index.html
2. By phone:
Call 1-800-368-1019.
TTY users can call 1-800-537-7697.
3. In writing: Send information about your complaint to:
Oce for Civil Rights
U.S. Department of Health & Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Need a copy of this booklet in Spanish?
To get a free copy of this booklet in Spanish, visit
Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY
users can call 1-877-486-2048.
Esta publicación está disponible en Español. Para obtener una
copia gratis, visite Medicare.gov o llame al 1-800-MEDICARE.
U.S. Department of Health & Human Services
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244-1850
Ocial Business
Penalty for Private Use, $300
CMS Product No. 10128 • 12/2023
The information in this booklet describes the Medicare Program at the time this booklet was printed.
Changes may occur after printing. Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the
most current information. TTY users can call 1-877-486-2048.
“Medicare Coverage of Kidney Dialysis & Kidney Transplant Services” isn’t a legal document. Ocial
Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.
You have the right to get Medicare information in an accessible format, like large print, braille, or audio.
You also have the right to file a complaint if you feel you’ve been discriminated against. Visit
Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE
(1-800-633-4227) for more information. TTY users can call 1-877-486-2048.
This product was produced at U.S. taxpayer expense.
