End Stage Renal Disease Services

Revised: March 26, 2026

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Billing

· Legal References

Overview

This section includes information on coverage policy and billing for Minnesota Health Care Programs (MHCP) fee-for-service members receiving renal dialysis and related services for end-stage renal disease (ESRD). The Department of Human Services (DHS) follows Medicare guidelines for coverage. For dually eligible Medicare patients, refer to the coverage policy and billing requirements from Medicare. Policy and billing structure follow Medicare guidelines from prior to 2005 as per our state plan and rate methodology. Not all information in this policy will align with current Medicare guidelines.

Eligible Providers

The following providers may enroll as renal dialysis facilities with MHCP:

· Medicare-approved ESRD facilities in hospitals

· Renal transplant centers

· Renal dialysis facilities and centers

· Outpatient hospitals

· Self-dialysis units

· Special purpose renal dialysis facilities

· Medical supply providers approved by DHS to provide ESRD services. DHS will approve only those medical suppliers who have provided home dialysis equipment and supplies to Medicare beneficiaries in the past 12 months.

Eligible Members

All MHCP members are eligible to receive renal dialysis and related services for ESRD. However, MHCP members receiving renal dialysis for ESRD must apply for Medicare benefits as soon as dialysis begins if they are eligible for Medicare coverage. Find more information on ESRD eligibility at the Medicare.gov ESRD website.

Covered Services

End Stage Renal Disease (ESRD)

MHCP covers the following services:

· Services provided in a renal dialysis facility (same as Medicare guidelines)

· Personnel (physician, licensed registered nurse, licensed practical nurse, technician, social worker, dietician)

· Equipment and supplies (dialysis machine and maintenance, disposable supplies)

· Some laboratory services (refer to the Laboratory Services section)

· Certain injectable drugs (such as heparin and its antidote) and biologicals

· Overhead and general administrative services

Composite claims are only billable by Medicare-approved ESRD facilities. Members may choose to receive their dialysis at a facility or perform their own home dialysis after receiving self-dialysis training certification.

Emergency Medical Assistance (EMA) and ESRD
Emergency Medical Assistance (EMA) (major program code EH) covers the care and treatment of emergency medical conditions provided in an emergency department (ED), or in an inpatient hospital, when the admission is the result of an ED admission.

See the Emergency Medical Assistance Coverage of Kidney Transplant Services and End Stage Renal Disease (ESRD) subsections for information specific to those services.

Physician Services

ESRD monthly capitation payment (MCP)
The monthly capitation payment (MCP) is a comprehensive monthly payment that covers all physician services provided in connection with uncomplicated and complicated renal dialysis sessions in outpatient maintenance dialysis facilities and at home.

· MCP is a monthly global physician service payment (based on Medicare policy prior to 2005) for outpatient dialysis and ongoing evaluation and management services related to outpatient dialysis

· Payment for physician services furnished to patients on continuous ambulatory peritoneal dialysis (CAPD) and continuous cycle peritoneal dialysis (CCPD) are covered under the MCP capitation rate.

The monthly payment for CAPD and CCPD include:

· Payment for both supervisory and direct care services routinely provided in connection with an ordinary course of maintenance dialysis

· For services related to the renal care of the patient

· Interpretation of the following tests:

· Bone mineral density studies

· Non-invasive vascular diagnostic studies of hemodialysis access

· Nerve conduction studies

· Electromyography studies

· All non-dialysis procedures are excluded from the MCP

Separately Billable
Any services that are unrelated to typical monthly ESRD with dialysis management are separately billable. These could include:

· Complete evaluation for renal transplantation.

· Evaluation of potential living transplant donors

· Non-renal related physician's services.

· Training of members to perform home or self-dialysis

When inpatient dialysis is necessary, the physician can be paid separately if the condition for which the member was hospitalized was not chronic renal disease. If the member was only hospitalized to receive maintenance dialysis (such as, the only diagnosis on the claim is ESRD), the dialysis is considered an outpatient service and reimbursed under the MCP

Transportation To and From Facilities

Coverage policy and billing instructions are in the Transportation Services section of this manual.

Payment Limitations

MHCP follows Medicare Payment Guidelines from prior to 2005 for ESRD.

MHCP limits payments in the following circumstances:

· MHCP covers dialysis and related services for the first three months of therapy under fee-for-service. Members must submit a formal application to the Social Security Administration to apply for Medicare coverage for dialysis services. If SSA denies Medicare coverage, attach a copy of the denial to the ESRD claim.

· When used in the treatment of life-threatening drug overdose, hemoperfusion is a covered service for patients with or without renal dialysis. Hemoperfusion is also covered when used in conjunction with deferoxamine (DFO) to treat aluminum toxicity.

· Apheresis is covered in renal patients only when performed as plasma exchange in the treatment of glomerulonephritis associated with anti-glomerular basement membrane antibodies and advancing renal failure or pulmonary hemorrhage.

· All E/M services related to the patient's ESRD, rendered on a day when dialysis is performed and all other patient care services rendered during the dialysis procedure are included in the dialysis procedure.

· If the facility fails to furnish any part of the items and services covered under the composite rate, either directly or under arrangements, MHCP will not pay for any part of the services provided.

· Medicare must approve separately billable drugs for coverage and may only be billed by an ESRD facility if they are administered in the facility by the facility staff.

· MHCP will not directly pay home health agencies for dialysis-related services provided in the home or a facility.

· Erythropoietin (EPO) is not separately covered when administered in a renal dialysis facility under the "incident to" provision.

· Artificial kidney machines, accessories and dialysis supplies can only be used for dialysis patients. DHS pays for rental only, no purchase of equipment unless the Social Security Administration denies Medicare coverage for the member.

· Water purification systems are covered for patients on home hemodialysis. DHS will cover either a deionization or reverse osmosis system, but not both for the same patient at the same time.

Noncovered Services

The following are not covered when provided by a dialysis facility:

· Items or services not medically necessary for the diagnosis or treatment of ESRD

· Hemoprofusion used to improve the results of hemodialysis or in conjunction with deferoxamine (DFO) to remove iron overload

· Apheresis used before or after kidney transplant services

· Missed appointments. If the facility prepares for a dialysis treatment, but the treatment is never provided, no payment is made

Billing

Refer to the Renal Dialysis Billing page.

Legal References

Minnesota Rules, 9505.0170 (eligibility for medical assistance payments)
Minnesota Rules, 9505.0210 (Covered Services; General Requirements)
Minnesota Rules, 9505.0392 (Compliance with Medicare Requirements)
Code of Federal Regulations, title 42, section 413, subpart A (provisions for Medicare payments)
Code of Federal Regulations, title 42, section 405, subpart U, and sections 405.2100-405.2184 (Conditions for Coverage of Suppliers of ESRD Services)