When Do You Qualify for Hospice on Dialysis or With ESRD?

End-stage renal disease (ESRD) most often qualifies for hospice when a person stops or declines dialysis — but there is an important nuance about dialysis you continue for a different illness. Here's how it works, in plain language.

The short answer

• The core test: a hospice doctor (and your regular doctor, if you have one) certifies a prognosis of six months or less if the kidney disease runs its normal course.
• The usual trigger: Medicare's regional coverage guidance for kidney disease starts with a patient who is not seeking dialysis or a transplant, or is discontinuing dialysis, plus lab evidence of very low kidney function (details below).
• Being on dialysis does not automatically disqualify you. Medicare's guidance says no regulation bars dialysis patients from electing hospice, but continuing dialysis changes the prognosis, and if hospice is elected for the kidney disease, the hospice must pay for any dialysis out of its daily rate.
• If hospice is for a different illness (for example, cancer) and dialysis is unrelated, Medicare can keep paying for dialysis separately.

The dialysis nuance

ESRD means the kidneys have failed and the body needs dialysis (a machine that filters the blood) to survive. There are two very different situations:

• Hospice because of the kidney failure. If a person with ESRD decides to stop or not start dialysis, the kidney disease itself becomes the terminal illness, and prognosis without dialysis is typically short. This is the most common path to a hospice benefit for ESRD.
• Hospice for a separate terminal illness, while continuing dialysis. A person can enroll in hospice for an unrelated terminal diagnosis (for example, advanced cancer) and keep getting dialysis, because that dialysis treats a different condition, not the illness hospice was elected for. Medicare's coverage guidance says this is the only situation in which a person can use both the hospice benefit and the ESRD (dialysis) benefit at once. Whether the kidney disease counts as related to the terminal illness is a clinical judgment the hospice makes and must put in writing (see below).

The curative-vs-terminal interaction

The key idea behind the Medicare Hospice Benefit is that you are choosing comfort-focused care for a terminal illness instead of treatment aimed at curing that illness. If hospice is elected for the kidney disease and dialysis continues, Medicare does not pay for that dialysis separately: the hospice is financially responsible for it, with no payment beyond its daily rate, and the continued dialysis may mean the six-month prognosis no longer holds. In practice, that is why ESRD hospice admissions usually follow a decision to stop dialysis; ask any hospice directly whether it offers dialysis to patients admitted for kidney failure. Dialysis for a kidney condition that is unrelated to the hospice diagnosis is treated separately. This is exactly where families get confused, and it is worth asking the hospice to spell out in your specific situation.

Two scenarios, side by side

It helps to see how the same person can land in very different places depending on what the dialysis is for. This table is a general illustration, not a coverage ruling — your hospice's medical team decides your specific case.

Kidney failure hospice eligibility criteria

Medicare contractors publish regional guidance called Local Coverage Determinations (LCDs) that describe what hospice doctors look for. They are guidelines, not a pass/fail checklist, and the numbers differ by region. Two examples:

• LCD L33393 (Wellpoint Federal; covers hospices in states including California, New York, New Jersey, Michigan, Washington, and New England): the patient is not seeking dialysis or a kidney transplant, or is discontinuing dialysis, plus one of: creatinine clearance under 10 cc/min (under 15 for people with diabetes), or under 15 (under 20 for diabetes) with congestive heart failure; serum creatinine over 8.0 mg/dl (over 6.0 for diabetes); or estimated GFR under 10 ml/min. For chronic kidney disease, signs of kidney failure can take the place of a lab value: uremia, very low urine output (under 400 cc a day), potassium over 7.0 that does not respond to treatment, uremic pericarditis, hepatorenal syndrome, or fluid overload that does not respond to treatment.
• LCD L34538 (CGS; covers hospices in states including Pennsylvania, Virginia, Maryland, Colorado, and Iowa): the same starting point on dialysis, with a GFR under 15 ml/min or serum creatinine over 8.0 mg/dl (over 6.0 for diabetes), and similar supporting signs.

Other illnesses (such as heart failure, lung disease, or cancer) count as supporting evidence. Which LCD applies depends on the hospice's Medicare contractor, so ask the hospice. The deciding question is still the physicians' judgment that prognosis is six months or less if the disease runs its normal course. For the first benefit period, both the hospice medical director (or a hospice physician) and your attending doctor, if you have one, certify that judgment. Our guide on how to qualify for hospice with kidney failure walks through the referral steps.

Who pays for dialysis if you keep it

• Hospice elected for the kidney disease: the hospice is responsible for any dialysis it agrees to provide, and Medicare pays it nothing extra for it.
• Hospice elected for an unrelated illness: the dialysis facility bills Medicare outside the hospice benefit, flagged as treatment of a condition not related to the terminal illness. Normal Medicare rules apply, so you owe the usual deductible and coinsurance. If you kept a Medicare Advantage plan, you can get care unrelated to the terminal illness, such as this dialysis, through your plan (paying the plan's copayments) or through Original Medicare.
• Get it in writing: for hospice elections starting on or after October 1, 2026, every hospice must give you a written election statement addendum within the first 5 days listing the conditions, items, services, and drugs it considers unrelated to the terminal illness, with a plain-language clinical explanation. If dialysis is meant to continue outside hospice, check that it appears there.

A common misconception

Many families believe that being on dialysis automatically blocks hospice, or that lab numbers alone decide eligibility. Neither is fully true. The relationship between dialysis and hospice depends on which illness the dialysis is treating, and eligibility is a clinical determination by physicians — not a checklist the family scores. This page tells you what to ask, not whether your loved one qualifies, and it is not medical advice.

What stopping dialysis usually looks like

Families often fear that choosing hospice over dialysis means being left without support. The opposite is intended. When someone with ESRD decides to stop dialysis, hospice care focuses on managing the symptoms that can follow — such as fluid buildup, nausea, itching, confusion, and shortness of breath — with medication, nursing visits, and support for the family at home. The decision to stop is the patient's (or their decision-maker's) to make, ideally after an honest conversation with the kidney doctor about what to expect. Hospice does not push that decision; it supports comfort once it has been made.

What hospice provides once enrolled

After enrollment, an interdisciplinary team works to keep the person comfortable wherever they live. For ESRD specifically, common areas of focus include:

• Fluid and breathing. Without dialysis, fluid can build up; positioning, medication, and sometimes low-dose opioids ease the sensation of breathlessness.
• Itching and nausea. Uremic symptoms are treated with targeted medications.
• Confusion and restlessness. The team explains what to expect and manages agitation gently.
• Medications and equipment for the terminal illness are covered under the Medicare Hospice Benefit, generally with a prescription copay of no more than $5 per drug for comfort medicines.
• Emotional and spiritual support from social workers and chaplains, plus bereavement support for the family for up to a year afterward.

Remember that under Routine Home Care, the benefit does not pay for room and board; if the person lives in a nursing home, that bed is billed separately, though Medicaid may cover it for dual-eligible patients in participating states.

What varies by setting and payer

• At home: the hospice team visits intermittently and is reachable 24/7 by phone; aides are not around-the-clock.
• In a nursing home: hospice layers its services on top of the facility's care, but the room-and-board charge is separate from the hospice benefit.
• Medicare Advantage: the hospice benefit is still paid through traditional Medicare even if the person has an Advantage plan.
• Dialysis logistics: if dialysis continues for an unrelated illness, who arranges and pays for it must be worked out with the hospice and the dialysis center up front.

Frequently asked questions

Can I stay on dialysis and still get hospice?

Yes, Medicare pays for both only when hospice is elected for a different terminal illness and the dialysis is unrelated to it. If kidney failure itself is the hospice diagnosis, no regulation forbids dialysis, but the hospice must pay for it from its daily rate and continued dialysis may change the prognosis, so many families find it is not offered. Ask the hospice to map this out for your exact situation.

How long do people live after stopping dialysis?

The National Institute of Diabetes and Digestive and Kidney Diseases says a person who needs dialysis to survive and does not receive it may live a few days or weeks. It varies with the person and their other conditions, and your nephrologist can give the most realistic picture. The point of hospice is not to predict a date but to keep the person comfortable through whatever time remains. Prognosis is a physician's judgment, never a guarantee.

Do I have to stop dialysis to ask about hospice?

No. You can request a hospice evaluation while still on dialysis to understand your options. The decision to continue or stop is yours, ideally made with your kidney doctor. "Request an evaluation" is always the right first step; no one can tell you in advance that you "qualify."

What lab values qualify kidney failure for hospice?

It depends on your region's LCD. In one widely used LCD (L33393), examples are creatinine clearance under 10 cc/min (under 15 with diabetes), serum creatinine over 8.0 mg/dl (over 6.0 with diabetes), or GFR under 10 ml/min, along with not pursuing dialysis or a transplant. Another region's LCD (L34538) uses GFR under 15 ml/min. Labs support the doctor's six-month prognosis; they do not decide eligibility on their own.

Will hospice cover my kidney medications?

Hospice covers medications and equipment related to the terminal illness it was elected for, with a comfort-drug copay of no more than $5 per prescription. Coverage of medications tied to a separate condition depends on the arrangement; ask the hospice to confirm what is and isn't included.

What to do next

If your loved one has ESRD and is weighing whether to continue dialysis, or has a separate serious illness alongside kidney disease, the right step is to request a hospice evaluation and ask whether there is any charge. The hospice's medical director or physician — not the family — confirms eligibility and explains how dialysis fits your situation. Ask the nephrologist or primary doctor for a referral, or contact a hospice directly.

Questions to ask the hospice

• If we stop dialysis, what symptoms should we expect and how will you manage them?
• If we keep dialysis for a different illness, who arranges and pays for it?
• Which medications and equipment will the benefit cover in our case?
• How quickly can a nurse reach us after hours?
• What support do you offer the family before and after the death?

For other treatments families ask about, see dialysis, IV antibiotics, and IV fluids on hospice. When you're ready to compare Medicare-certified hospices near you, search our directory by city. You may also want to read how Medicare covers hospice care and the difference between hospice and palliative care.