If your kidneys have failed, you will need dialysis treatment. Dialysis — whether performed at home or at a dialysis facility — is not just time consuming, it can also be expensive. As health costs rise, you may be concerned about your ability to afford your treatment. The majority of dialysis costs are paid through medical insurance — either your own insurance or the government-sponsored Medicare program. A member of your health care team, your social worker, can help you explore different insurance options as well as government assistance programs for people who need dialysis.
Your medical insurance is insurance that is provided by your employer at work or insurance that you purchase for yourself.
Medical insurance provided by your employer at work is called an employer group health plan (EGHP). If you are retired and receive medical benefits from your former employer as part of your pension plan, this is also considered an EGHP. Many people believe if they must go on dialysis, they must quit their jobs. In most cases, this is not true. Although kidney disease may make you feel ill, dialysis can help you feel better so you can continue to work. People in different stages of kidney disease are able to continue their employment.
As long as you are physically able to meet the demands of your job, your social worker will recommend you continue working in order to have coverage under your EGHP. Your EGHP can help pay for the majority of your dialysis costs, as well as any medicines you need and your doctor’s visits. Questions about your health benefits should be addressed to your company’s Human Resources Specialist or a Benefits Analyst. They can explain your coverage and refer you to the health plan’s administrator if you have specific questions about what medical conditions are covered and how much they are able to pay. Some companies have their medical coverage with a Health Maintenance Organization (HMO). Depending on the HMO, you may have the option of receiving treatment at their facilities if they offer it. If you are retired and receive medical benefits as part of your pension plan, this also falls under EGHP.
Some people decide to buy insurance on their own if their employer does not provide medical insurance, if they do not like the benefits their EGHP offers or if they are not eligible for their EGHP. If you have personal medical insurance, you must pay a fee (called a premium) on a monthly, quarterly or yearly basis. The dialysis costs covered vary from plan to plan. One of your health plan’s administrators can tell you what is covered and what your out-of-pocket costs may be. If you are looking to purchase a private plan to help offset the costs of dialysis, ask about the plan’s policy on pre-existing conditions. A pre-existing condition is a health condition you received treatment for before joining their plan. Some insurance policies have restrictions on paying for treatments for pre-existing conditions.
If you do not have an EGHP or private insurance and you need dialysis, you may qualify for the government-sponsored medical insurance called Medicare.
Medicare is not just for people who are 65 or older. In 1972, the Social Security Act extended all Medicare benefits to people of any age with end stage renal disease (ESRD) who need dialysis if they meet the following requirements:
Medicare is divided into two parts: Medicare Part A and Medicare Part B. (As of January 1, 2006 Medicare added a third part, Medicare Part D, which deals with prescription drug coverage. This article does not refer to that area of Medicare.) Medicare Part A is hospital insurance. If you need to be admitted into a hospital, Medicare will help cover those costs. Medicare will also help cover the costs of a nursing facility and hospice care as well as some home health care. When you turn 65, you get Part A automatically because you or your spouse paid Medicare taxes when you were working. You will not be charged any monthly fee or premium for Part A because you or your spouse paid Medicare taxes when you were working.
The other part of Medicare is Part B. Part B pays for doctor’s appointments, outpatient hospital care and other services that Part A does not cover. If you have services or supplies that are medically necessary (supplies like dialysate if you are on peritoneal dialysis), Part B helps pay for those costs. Enrollment in Part B is not automatic. You must request enrollment in Part B. Also, Part B charges a premium. If you stop paying your premiums, your coverage under Part B will stop.
Dialysis patients need Part A and Part B of Medicare to cover certain dialysis and kidney transplant procedures. If you already have Medicare but decided not to enroll in Part B, you may find that the premium for Part B has increased. This increase in premium may be waived if you sign up for Part B because you have renal disease.
If you need to enroll in Medicare because of ESRD and you are under the age of 65, you can sign up at a local Social Security office. If you have not paid enough into Social Security to qualify for Medicare, you can pay a premium to enroll in Medicare if you have ESRD. Your social worker can advise you and help with the paperwork.
For patients who were automatically enrolled in Medicare because they are 65 or older, Medicare coverage for dialysis begins right away. However, if you are under 65 and only eligible for Medicare because of ESRD, your Medicare coverage for dialysis will not begin right away. Coverage will start right away for peritoneal dialysis patients and on your fourth month of dialysis treatments for hemodialysis patients. Until then, your medical insurance will be the primary coverage. This is why it’s important to keep your EGHP or other medical insurance active.
When Medicare coverage begins on the fourth month, your EGHP insurance will continue to help pay the costs of your treatment. This is called a coordination period. Your personal medical insurance will pay first on your medical bills and Medicare will be the second payer. If there are still costs after your personal medical insurance has paid for your treatment, Medicare, as the second payer, may help cover these remaining expenses.
At the end of the coordination period (30 months), Medicare will pay first for your treatment and will become your primary insurance coverage. If there are still costs left over after Medicare has paid, your personal insurance may pay for the remaining expenses.
Most dialysis facilities are knowledgeable about insurance billing. If you have an EGHP or personal medical insurance, make sure they know so that your treatments can be billed properly.
If you need financial assistance because of out-of-pocket costs that are not covered by Medicare and/or your medical insurance, your social worker has information about other programs that can help pay for your dialysis. Your social worker is a valuable resource when it comes to information about different state, federal and private programs that are aimed to help patients with chronic kidney disease (CKD).
Medicaid is a joint state and federal funded program that helps pay medical costs for people with limited resources. If you are not eligible for Medicare, you may be eligible for Medicaid. Medicaid coverage varies from state to state, so ask your social worker if you are eligible and how to apply.
If you are a veteran, the Department of Veteran Affairs has a program for vets who need dialysis. Retired military personnel and their spouses may also be eligible for assistance with costs related to dialysis. Your social worker will have more information about eligibility.
Private programs can also help offset your medical costs. Most pharmaceutical companies have patient assistance programs for people who have difficulty affording their prescription drugs. The American Kidney Fund has a program to help pay premiums on Medicare Part B or your supplemental insurance. The National Kidney Foundation offers financial assistance with medications as well as emergency assistance for those with kidney disease.
Talk to your social worker. He or she can put you in touch with the resources you need and help you explore all the options available to you. Social workers can provide you with assistance and support. All you need to do is ask.
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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