Who pays your dialysis bills when you have end stage renal disease (ESRD)? Does the government pay through Medicare or does your insurance plan at work cover the treatment costs? You may have heard the term Coordination of Benefits (COB). This is the period where your employer group health plan (EGHP) and Medicare insurance work together to help pay for your dialysis bills. The following information is for people on dialysis who have EGHP and Medicare.
Many people who need dialysis may be covered by an employer group health plan (EGHP) either through their own job or their spouse’s. Depending on how much of your dialysis bill is covered by the employer’s plan, consider applying for Medicare insurance. If you decide to have both EGHP and Medicare, you will likely have to complete a COB period. The time when your employer’s plan is the primary payer for your dialysis is called the “Coordination of Benefits” period, because Medicare is “coordinating” your private insurance with Medicare.
The Coordination of Benefits period is the 33 months (if you choose in-center hemodialysis) or 30 months (if you choose home hemodialysis or peritoneal dialysis) after you start dialysis. During this time your employer’s insurance is the primary payer and Medicare is the secondary payer. As the primary payer, the employer plan pays according to your policy and benefits. Medicare, as the secondary payer, usually covers the portion that the employer group health plan did not already pay. For instance, if your EGHP pays for 80% of your dialysis bill, Medicare generally pays the other 20%.
You are eligible to receive Medicare for the following reasons:
When you have an employer group health plan and want to apply for Medicare, the work status of the policy holder (you or your spouse) affects whether or not you will be in a Coordination of Benefits period.
If you have an employer’s plan and apply for Medicare, you should figure out when to request this type of insurance. Applying for Medicare when you have employer’s insurance is patient-specific and needs to be reviewed on a patient-by-patient basis, because sometimes the employer’s plan pays the entire cost of dialysis. Ask your social worker for more information about paying for your dialysis care and Coordination of Benefits.
If you choose in-center hemodialysis, there is a three-month waiting period from the date you start dialysis before Medicare begins to pay for dialysis services. During these three months, your employer’s group health plan is usually the only payer. After the three-month waiting period, the 30-month Coordination of Benefits period begins, for a total of 33 months that your employer’s plan is the primary payer.
If you choose peritoneal dialysis (PD) or home hemodialysis (HHD) within the first 90 days of starting dialysis, there is no three-month waiting period for Medicare to begin paying. From the date you start home dialysis, your employer’s insurance is primary and Medicare is secondary for 30 months.
When the Coordination of Benefits period ends, Medicare becomes your primary payer, and your employer’s insurance becomes the secondary payer. Medicare pays for 80% of the dialysis treatment costs and your employer group health plan, as secondary payer, usually pays the other 20% that Medicare does not cover. Many EGHPs also provide payment for prescription drugs, but coverage depends on the specific health plan policy.
When you have an employer group health plan (EGHP) and need dialysis, you may want to apply for Medicare to supplement the portion of your dialysis bills that is not covered by your EGHP. These insurance policies – EGHP and Medicare – can coordinate with each other to help pay your dialysis bills, through the Coordination of Benefits (COB) period. Talk with your social worker to learn more about who pays your dialysis bills.
This site is for informational purposes only and is not intended to be a substitute for medical advice from a physician.
Please check with a physician if you need a diagnosis and/or for treatments as well as information regarding your specific condition. If you are experiencing urgent medical conditions, call 9-1-1