Dialysis cost per treatment with Medicare: your 20 percent in 2026 and 2027

The 2027 budget-neutrality factor of 0.98864 is itself a product of three budget-neutral changes: 0.98901 for expanding the low-volume payment adjustment, 0.99999 for the new pediatric adjusters and 0.99964 for the larger home training add-on. Multiplied together they give 0.98864. The market basket update is 2.9 percent less a 1.0 point productivity adjustment, which is how CMS arrives at 1.9 percent (91 FR 68768). The low-volume expansion alone lowers the base rate by about 1.1 percent, roughly $3, according to CMS's fact sheet, and it does so to pay more to facilities that furnish fewer than 8,000 treatments a year; for a patient at a facility above 8,000 treatments a year, the same change takes about $3 off the base rate and returns nothing.

Why a 5.6 percent headline overstates the raise

Comparing $297.52 with $281.71 gives 5.6 percent, and that is not the change in what a typical patient's 20 percent will be. Of the $15.81 difference, $12.85 is phosphate binders being moved into the base rate. Oral phosphate binders have been paid under the ESRD PPS since January 1, 2025 through a transitional drug add-on payment adjustment, the TDAPA, which was set at 100 percent of the drug's average sales price plus a flat $36.41 a month per patient claim for operating costs (91 FR 68775). That add-on sat on top of the $281.71 base rate in 2026 and ends December 31, 2026. In 2027 the cost is spread across every treatment as $12.85 in the base rate. CMS reached that line by multiplying binder drug spending from April 2025 through June 2026 by 1.06 for operating costs and dividing by all paid treatments, which gave $12.98 per treatment, and then cutting it 1 percent for the outlier policy (91 FR 68780). With the binder line subtracted, the base-rate difference is $2.96.

CMS's own estimate is the better guide. The rule projects that total ESRD PPS payments rise 2.7 percent in CY2027 compared with CY2026, counting the market basket update, the end of the TDAPA for three drugs, the new base-rate line for binders and the add-ons that replace the TDAPA after it ends. Because the patient owes 20 percent of the payment, the rule states the beneficiary effect directly: coinsurance payments are projected to rise 2.7 percent, about $50 million across all beneficiaries (91 FR 68738). The 2.7 percent is an aggregate across all patients and all payments, so it does not forecast any one patient's bill. It does show why the base-rate arithmetic, $56.34 rising to $59.50, overstates the typical change: the 2026 per-treatment payment included add-ons that are not in the $281.71 figure.

Those add-ons carry the same 20 percent. The manual's coinsurance section lists TDAPA and the post-TDAPA add-on among the pieces of the total ESRD PPS payment on which coinsurance is figured. In the first quarter of 2027, CMS finalized post-TDAPA add-on amounts of $0.0793 per treatment for Korsuva, $8.3220 for DefenCath and $0.9970 for Vafseo; the Korsuva amount applies to the first quarter only, and the other two are included each quarter of 2027. Each quarter's amount is added to payments for all treatments in the quarter and is adjusted by the patient-level factors. For the reference patient, the three together are $9.40, which would lift the first-quarter treatment payment to $306.92 and the patient's 20 percent to $61.38. The later quarters are set by CMS change requests, so those later figures are not published in the rule.

The outlier payment is the other piece that does not show in the base rate. A facility receives an outlier payment when its imputed cost of certain drugs, labs and supplies for a patient exceeds a predicted amount plus a fixed-dollar loss. For adults CMS moved the predicted amount from $23.68 to $41.83 and the fixed-dollar loss from $14.80 to $90.60, which lifts the per-treatment threshold from $38.48 to $132.43. The Benefit Policy Manual's worked outlier example pays the facility 80 percent of the amount above the threshold. Any outlier payment is part of the total on which the patient's 20 percent is figured. CMS expects the higher thresholds to reduce 2027 payments by about 1.6 percent, and it estimates outlier payments will be about 2.6 percent of total ESRD PPS payments in CY2026.

CMS publishes one all-in figure that avoids the add-on bookkeeping. To set the dollar limit on a Medicare Advantage plan's dialysis copayment, CMS's actuaries project the average Medicare fee-for-service allowed amount per dialysis session, including facility fees, approximated physician fees and Part B drug costs, weighted across all dialysis types and settings. The projection is $345.25 for 2026 and $349.00 for 2027, a 1.1 percent change. Twenty percent of those averages is $69.05 and $69.80 per session, or $10,771.80 and $10,888.80 over 156 sessions. Those averages sit above the base-rate math because they include the pieces on top of it, and they describe an average across many facilities and patients, not any one bill.

Patient adjusters that move the 20 percent

The payment for one treatment is the wage-adjusted base rate multiplied by a set of patient-level factors, plus the add-ons. 42 CFR 413.230 states the sum: the base rate adjusted for wages, facility characteristics and patient characteristics, plus any outlier payment, any training add-on and the transitional add-ons. The adult factors below were set in the CY2016 final rule (80 FR 68993 to 68994, Table 4) and are restated in the Benefit Policy Manual (chapter 11, section 60.A.1). The CY2027 final rule describes the adult adjusters (91 FR 68739) and changes only the onset factor among them, so the other multipliers apply in both years; the onset factor is the exception, changed for 2027 for a separate reason covered below.

The manual's own worked example shows how the pieces multiply. A 45-year-old with a height of 187.96 cm and a weight of 95 kg has a body surface area of 2.2161, so the BSA multiplier is 1.032 raised to the power 3.161, or 1.1047. Times the 1.068 age multiplier that is 1.1798, and at a wage index of 1.000 the CY2026 payment is $281.71 x 1.1798, or $332.36; the manual prints $332.36. Under the CY2027 base rate the same patient's payment is $351.01. Two other body sizes show the range of the exponent: a BSA of 2.10 gives a multiplier of 1.065, and a BSA of 1.70 gives 0.9389.

Three rules of the system limit stacking. A treatment in the onset period is not eligible for a comorbidity adjustment, and under the current manual text it is also not eligible for the training add-on; the 2027 rule reverses that second limit, as the home training section below explains. Only one comorbidity factor applies even if several conditions exist. And the factors above are for adults: patients under 18 use two age groups and two dialysis modalities instead, and the temporary 30 percent pediatric add-on ends on December 31, 2026, replaced from 2027 by revised pediatric adjusters.

Acute kidney injury dialysis furnished by an ESRD facility is paid at the same base rate, $281.71 in 2026 and $297.52 in 2027, and the patient still owes 20 percent. The manual says that only the wage index and, since January 1, 2025, the home and self-dialysis training add-on apply to those claims; the case-mix and facility adjusters do not.

Wage index and labor share

The wage index multiplies only the labor-related part of the base rate. The remaining share is paid at the national amount. For CY2026 the labor-related share is 55.2 percent; the CY2027 rule rebases the ESRD market basket to 2024 and raises the share to 63.5 percent, an increase of 8.3 points (91 FR 68757). The index itself has a floor of 0.6000 and a rule that limits any facility's drop to 5 percent a year (42 CFR 413.231(c) and (d)). So a facility with a wage index above 1.000 gains more in 2027 than one below it.

The table below applies the same illustrative wage index to both years, for the reference patient, so the effect of the labor share shows without the separate yearly change in each facility's index. Real wage indexes are published each year for each area and move; these six values are not any named facility's.

The spread from the floor to a 1.2000 index is $93.30 a treatment in 2026 and $113.36 in 2027, so two patients with identical characteristics can owe different dollar amounts for the same session depending on where the facility is. CMS acknowledges the redistribution in the rule: for a facility at the 0.6000 floor, the move to the higher labor share alone lowers payment by 4.3 percent, and CMS declined to phase it in. In the table, the floor row rises only 1.1 percent because the 5.6 percent higher base rate is mostly cancelled by that 4.3 percent loss, while the 1.2000 row rises 7.2 percent.

A treatment, a year, and the 156 count

Five invented patients show how the factors turn into the patient's share. Each row is a payment per treatment computed from the national rate and the multipliers above; none includes outlier payments, the training add-on or the post-TDAPA add-ons. The annual columns multiply by 156 treatments and take 20 percent of the year's total.

For the reference patient, 156 treatments at $281.71 total $43,946.76, and 20 percent of that is $8,789.35. Multiplying the rounded $56.34 by 156 gives $8,789.04, a few cents different, because the year's figure is taken on the total and a claim rounds each line. In 2027 the same patient's year is $46,413.12 and the 20 percent is $9,282.62, which is $493.27 more than in 2026 on the base rate alone. The onset row shows how much the first four months weigh: the 2026 factor of 1.327 puts the reference treatment at $373.83, and the 2027 factor of 1.311 puts it at $390.05. A patient's first 120 days hold about 51 treatments at three a week.

These are anchors for judging order of magnitude. A given facility's payment can be higher or lower than any row for reasons already listed, and a patient in a Medicare Advantage plan or with a Medigap policy may owe a very different amount, as the coverage section below shows.

The Part B deductible comes first

Original Medicare charges the Part B deductible before it starts paying its 80 percent. The 2026 amount is $283, from CMS's fact sheet of November 14, 2025 and the Medicare & You 2027 handbook. CMS had not published a 2027 Part B deductible by November 3, 2026, and the handbook, which describes 2027 coverage, still prints the 2026 figure of $283. Every annual figure in this guide is 20 percent of approved amounts, with the deductible effect stated separately ($226.40 at the 2026 amount). The rule for any new amount is simple arithmetic: each additional $10 in the deductible adds $8.00 to what a patient without supplemental coverage pays, because the deductible replaces 80 percent of that $10 that Medicare would otherwise have paid.

Dialysis shows how the deductible works unusually clearly, because the facility's first treatment of the year is smaller than the deductible. The reference payment of $281.71 is $1.29 below $283. The first approved amounts of the year count toward the deductible in the order claims are processed, so the arithmetic for the first three treatments is:

The patient owes the whole first treatment, $281.71, then $57.37 for the second, and from the third onward the $56.34 that is 20 percent. Over the year the deductible adds $226.40 to the plain 20 percent, which is 80 percent of $283. Dialysis facility claims are monthly, so a Medicare Summary Notice shows the deductible inside the first month's claim and not treatment by treatment. Other Part B services in the same year, including the kidney doctor's monthly fee below, draw on the same deductible, and whichever claim is processed first absorbs it. A Medigap policy that pays the Part B deductible, or a program such as QMB that pays Medicare cost sharing, takes that arithmetic off the patient; the guide to Medicare Savings Programs covers who qualifies, and the guide to what Medicare patients pay for an outpatient procedure shows the same deductible ordering on a procedure claim.

Home dialysis and the training add-on

Medicare.gov says Part B covers home dialysis training for the patient and the person helping with treatments, and that the patient pays 20 percent of the Medicare-approved amount after the deductible. Training is paid through the same bundled rate with an add-on for the nursing time. The Claims Processing Manual (chapter 8, section 50.8) says the add-on is adjusted by the facility's wage index and added to the base rate, applies to both hemodialysis and peritoneal dialysis training, and is payable for at most 25 hemodialysis training sessions per patient and 15 peritoneal dialysis training sessions (CAPD or CCPD), and the Medicare contractor decides whether peritoneal dialysis training beyond 15 sessions is permitted.

The add-on is $95.60 for 2026 and $138.00 from January 1, 2027, a rise of $42.40 or 44.4 percent. CMS set the $95.60 figure in the CY2017 rule from 2.66 hours of registered nurse time; the 2027 amount keeps the 2.66 hours and updates the nurse wage to $51.88 an hour, so 2.66 x $51.88 = $138.00 (91 FR 68811). CMS notes that Medicare paid about $7 million in training add-ons in 2025, about the same as in prior years, and says that flat trend may indicate that home and self-dialysis remain underused and that training payment adequacy may be a factor. The coinsurance on the add-on alone is $19.12 per training session in 2026 and $27.60 in 2027, before the wage index. The manual's example at a 1.1000 wage index multiplies the 2026 add-on by 1.1 to $105.16; the 2027 add-on at the same index is $151.80.

Each session is the reference treatment payment plus the add-on, so the first row's $377.31 is $281.71 + $95.60. Of the first row's 20 percent, $478.00 (2026) and $690.00 (2027) comes from the add-on itself across a full hemodialysis course. The Claims Processing Manual (section 10.1) says the limit of three paid treatments a week, and 13 or 14 a month, does not apply to training and retraining treatments billed within the allowable limits, so sessions inside the 25 and 15 limits are paid as a treatment plus the add-on and sit outside the monthly cap.

The 2027 rule also lets the training add-on be paid during the onset period, the first 120 days of dialysis, which the current manual text bars. To avoid paying twice during those months, CMS lowers the onset factor from 1.327 to 1.311. The timing of coverage also matters here. Under 42 CFR 406.13(e), Medicare entitlement for a person with kidney failure begins on the first day of the third month after dialysis starts, so dialysis that starts in January leads to Medicare coverage on April 1. If, before the waiting period ends, the person takes part in a self-dialysis training program at a participating facility and meets the other conditions in paragraph (e)(4), entitlement begins in the month dialysis started.

The kidney doctor's separate monthly fee

The dialysis facility's payment excludes physician services. The Benefit Policy Manual says physician services are excluded from the ESRD PPS, and the Claims Processing Manual (chapter 8, section 140) pays the physician managing a patient's dialysis a monthly capitation payment that varies with the number of face-to-face visits in the month and with the patient's age. Payment is 80 percent of the Medicare-approved amount after the Part B deductible, and the beneficiary owes the deductible and 20 percent. For a patient who dialyzes at home, the physician is paid one monthly rate by age regardless of the number of visits, with at least one face-to-face visit a month.

The amounts come from the Physician Fee Schedule. The table prices the adult codes for CY2026 in Michigan Locality 01 (Detroit), using the October 2026 RVU26D relative values, the 2026 GPCIs and the $33.4009 conversion factor. Another locality's amount will differ.

The 90960 line rebuilds from its relative values: it carries 6.77 work RVUs, 3.96 practice expense RVUs and 0.43 malpractice RVUs. Multiplied by Detroit's 1.000, 0.965 and 1.686 indices, summed and multiplied by $33.4009, that gives $377.98. The facility and non-facility practice expense values for these codes are the same, so setting does not change the figure. Code 90960 pays 74.2 percent more than 90962 for the same month, so the number of visits matters, but both are small beside the facility layer: 13 reference treatments in a month come to $3,662.23, against $377.98 for the physician's monthly code. Per-day code 90970 is for a part month in the situations the Claims Processing Manual lists, such as a home dialysis patient for less than a full month, a patient traveling away from home, or a permanent change of managing physician.

The CY2027 Physician Fee Schedule was proposed on July 16, 2026, and the Federal Register's published and public-inspection lists showed no final rule through November 3, 2026, so the monthly amounts above are CY2026 figures with no 2027 counterpart yet. A physician that does not accept Medicare assignment may bill above the approved amount, up to the limiting charge; the guide to Medicare excess charges prices that ceiling.

Coverage that changes the 20 percent

For the reference patient in CY2026, Original Medicare with no supplemental coverage and no help from a state program leaves $8,789.35 on the facility layer (20 percent of $43,946.76) and $907.15 on the physician layer (20 percent of twelve months of code 90960, $4,535.76). The two layers are separate bills from separate payment systems, so they are shown side by side and not added into one figure. The Part B deductible comes on top once: $226.40 more than the plain 20 percent, taken from whichever Part B claim is processed first. The table sets the facility layer against four coverage arrangements; each row assumes a provider that accepts Medicare, in network where a plan has a network.

Medigap is the clearest case. Medicare & You 2027 (page 80) shows that most lettered Medigap plans pay 100 percent of the Part B coinsurance, that Plans K and L pay 50 and 75 percent until an out-of-pocket limit is reached ($8,000 for K and $4,000 for L in 2026), and that Plan N pays the coinsurance except for copayments of up to $20 for some office visits and up to $50 for emergency room visits. The same chart notes that Plans C and F cannot be bought by anyone who became eligible for Medicare on or after January 1, 2020. The handbook adds that federal law generally does not require insurers to sell Medigap to people under 65, and that some states do (page 81). A person who qualified for Medicare because of kidney failure can be under 65, and in that case whether a policy can be bought, and at what price, depends on the state. Medicare & You also notes (page 11) that Original Medicare has no yearly limit on what a person pays out of pocket, unless the person has supplemental coverage or other insurance.

Medicare & You says a person with ESRD can choose Original Medicare or a Medicare Advantage Plan (page 68). Advantage plans must set a yearly limit on in-network spending for covered Part A and Part B services. The CMS limit files show the ceilings below, along with the number of $70 treatments that would reach each ceiling if dialysis copayments were the only spending.

The $70 copayment limit in CMS's file is 20 percent of the projected average allowed amount per session ($345.25 in 2026 and $349.00 in 2027), rounded; the file lists a 20 percent coinsurance limit alongside it, so a plan may charge coinsurance instead of a copayment. A plan can charge less than either, and a plan with a lower MOOP type reaches its limit sooner. Whether the patient's facility and physician belong to the plan's network is a separate question for the plan. The guide to deductibles and out-of-pocket maximums explains how a plan counts spending toward a limit, and the guide to Part B infusion drug coinsurance sets out the same Medigap and MOOP comparison for a different open-ended Part B cost.

Employer coverage and the 30-month window

Whether Medicare's 20 percent matters at all depends first on who pays first. Medicare.gov explains that coverage usually cannot start until the fourth month of dialysis, and that an employer or union group health plan is the only payer for the first three months. Once a person becomes eligible for Medicare because of kidney failure, a 30-month coordination period begins in which the group plan pays first and Medicare second; at the end of it Medicare pays first for Medicare-covered services. If the group plan does not pay 100 percent, Medicare may pay some of the remaining costs. Under 42 CFR 411.162(a)(1) to (3), Medicare is secondary to the group plan for ESRD whatever the size of the employer or the person's employment status, and that includes COBRA continuation coverage.

A separate 30-month coordination period applies each time a person signs up for Medicare based on kidney failure, per Medicare.gov. For the cost question, this means a patient with a group plan with a deductible, copayment or coinsurance may see Medicare cover part of those costs as secondary payer, and may owe far less than the 20 percent computed here. When the coordination period ends, the arithmetic in this guide becomes the starting point unless a retiree plan, Medigap or Medicaid still sits behind Medicare. The Medicare Benefit Policy Manual points to the Medicare Secondary Payer manual for the coordination-of-benefits rules that apply to ESRD beneficiaries.

Charges that sit outside the bundle

The 20 percent on the facility's payment does not cover everything a dialysis patient can be billed for. Four separate situations produce separate Part B or Part A charges.

• Drugs and labs unrelated to kidney failure. A drug or lab test that a facility furnishes for reasons other than treating ESRD can be billed separately with the AY modifier (Benefit Policy Manual, chapter 11, section 20). That line has its own 20 percent, figured the way the guide to Part B infusion drug coinsurance describes for drugs paid from an average sales price limit.
• Vascular access surgery. The manual says creating or revising a patient's dialysis access is usually done in a hospital outpatient department, and that services furnished on the day of that procedure are not renal dialysis services; physicians bill them separately with the AY modifier. The procedure carries the usual professional share and hospital copayment shown in the guide to outpatient procedure costs for Medicare patients.
• Dialysis during a hospital stay. Medicare.gov says Part A pays for dialysis in a hospital after the inpatient deductible, which CMS sets at $1,736 for 2026, and the kidney doctor's monthly payment is based on the number of days in the hospital. Whether the stay is billed as inpatient or observation decides the layer, as the guides on hospital stay cost per day and observation versus inpatient status show.
• Items Medicare does not cover. Medicare.gov lists paid dialysis aides for home dialysis, lost pay during home training, a place to stay during treatment, and blood for home dialysis unless it is part of a doctor's service. Part B covers ambulance transport to and from the nearest dialysis facility only when traveling in any other vehicle could endanger health.

Checking a dialysis statement

A facility bills Medicare monthly, so the statements arrive as one claim a month. Five checks use only the figures above.

1. Count the treatments. A 30-day month is limited to 13 paid treatments and a 31-day month to 14, unless the facility documents medical justification for more. Three treatments a week is 156 a year, or 13 a month on average.
2. Divide the approved amount by the treatments. The result should land near a wage-adjusted, case-mix-adjusted version of the base rate. An average well under $219.51, the 2026 anchor at the floor index, or far above the reference patient's amounts, is a question for the facility about the wage index and patient-level factors on the claim.
3. Check the 20 percent. The coinsurance should equal 20 percent of the month's approved amount after the deductible has been taken from the first claim of the year.
4. Look for a separate 20 percent on a bundled lab or drug. The manual says those items carry no separate coinsurance. If the facility reprocesses a claim and the payment changes, the manual makes the facility responsible for reconciling any over- or underpayment of coinsurance with the patient.
5. No-shows. When a facility sets up for a treatment and the patient never arrives, no payment is made, and the Claims Processing Manual says the facility may not bill the patient or the patient's private insurance for it.

The guide to checking an itemized bill for errors covers raising a billing error, and the guide to reading an explanation of benefits shows where a plan's allowed amount sits on a statement.

Your dialysis cost questions answered

The rule texts behind each number

• Federal Register, CY 2027 ESRD PPS final rule, CMS-1846-F (91 FR 68736, October 30, 2026, FR Doc 2026-22194; effective January 1, 2027): base rate $297.52, binders $12.85, labor-related share, training add-on $138.00, onset factor, outlier amounts, post-TDAPA add-ons, projected coinsurance effect. Checked November 3, 2026.
• Federal Register, CY 2026 ESRD PPS final rule, CMS-1830-F (90 FR 53068, November 24, 2025; effective January 1, 2026): base rate $281.71. Checked November 3, 2026.
• CMS, fact sheets for the CY 2027 and CY 2026 ESRD PPS final rules: base rates, the $15.81 increase, the binder amount, the training add-on of $95.60 to $138.00. Checked November 3, 2026.
• Federal Register, CY 2016 ESRD PPS final rule (80 FR 68968, November 6, 2015), Table 4: adult case-mix and facility-level adjusters. Checked November 3, 2026.
• CMS, Medicare Benefit Policy Manual, chapter 11 (Rev. 13599, January 30, 2026), sections 20, 40, 50 and 60, and Medicare Claims Processing Manual, chapter 8 (Rev. 13740, April 17, 2026), sections 10, 50.8 and 140. Checked November 3, 2026.
• eCFR, 42 CFR 413.230, 413.231, 406.13 and 411.162, version in effect October 28, 2026. Checked November 3, 2026.
• CMS, Physician Fee Schedule relative value file RVU26D (released August 26, 2026) and CY2026 GPCIs, Michigan Locality 01, $33.4009 conversion factor: codes 90960, 90961, 90962, 90966 and 90970. Checked November 3, 2026.
• CMS, 2026 Medicare Parts A and B premiums and deductibles (November 14, 2025): Part B deductible $283, Part A deductible $1,736. Checked November 3, 2026.
• CMS, Medicare Advantage Rates and Statistics, CY 2026 and CY 2027 MOOP and Cost Sharing Limit Calculations: in-network MOOP limits and the dialysis services copayment limit. Checked November 3, 2026.
• Medicare.gov, Dialysis services and supplies and Medicare and end-stage renal disease; Medicare & You 2027 (PDF pages 11, 47, 68, 80 and 81). Checked November 3, 2026.

Scope: Original Medicare and Medicare Advantage costs for adult outpatient dialysis in the United States. Pediatric adjusters, acute kidney injury add-ons, the low-volume tier factors (printed as an image in the Federal Register) and the post-TDAPA amounts for quarters after the first quarter of 2027 are not tabulated. General billing information, not medical, legal or insurance advice. Medicare anchors are not your bill, and a facility's payment, a plan's cost sharing and a Medicaid program's rules can all differ from them. Confirm your price in writing.