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• What are the benefits of home dialysis?
• How is dialysis paid for?
• Besides Medicare, how is home dialysis and training covered?
• When does Medicare start if I take it?
• How does Medicare pay for dialysis?
• What is Medicare’s new bundled payment system?
• Will Medicare’s bundled payment affect me?
• How does this change affect payment for home dialysis?
• Will my clinic charge more under bundled payment?
• Should I take Medicare if I have employer coverage?
• How do employer plans and Medicare work together to pay for home dialysis?
• How does Medicare pay for home training under the new payment system?
• How does Medicare pay clinics for my home dialysis machine, support equipment, and supplies?
• How many sessions will Medicare cover for home hemodialysis training?
• How many home HD treatments will Medicare cover?
• How many sessions will Medicare cover for PD training?
• Will Medicare pay for re-training?
• How does Medicare pay for PD treatments when it is the primary payer?
• Will Medicare pay for a home helper if I need one?
• If I hire a home dialysis helper, will Medicare still consider me to be a home (self-care) patient?
• If I cannot do home dialysis for a while, can I keep my machine, and will Medicare pay for it?
• What kind of support for my home dialysis should I expect my clinic to provide?
• Can I keep my job?
• Will Medicare pay if I travel with home dialysis?
• Who can explain my insurance coverage and dialysis billing to me?
• Who can help me if I have problems paying my bills for premiums or healthcare?

What are the benefits of home dialysis?

Patients have reported a number of benefits related to home dialysis, including:

• Choosing a treatment that fits your lifestyle.
• Getting Medicare the first of the month dialysis starts if you start training before your third full month of dialysis.
• Having more flexibility in scheduling dialysis so you can arrange it around other activities you want or need to do instead following someone else’s schedule.
• Keeping your job, your income, and your company’s health insurance.
• Understanding more and feeling in more control.
• Saving money for transportation to clinic with 1–2 clinic visits instead of 13 or 14.
• Having lower infection risk because you are not exposed to others’ germs.
• Protecting your access if only you or your care partner is using it.
• Being more comfortable in your home where you can eat and drink, have visitors, watch TV or listen to music without earphones, play games with family, etc.
• Living longer and eating better.

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How is dialysis paid for?

Most people who are working or have worked long enough and who paid Medicare taxes can get Medicare when they start dialysis or have a transplant. If you haven’t worked long enough, you can get Medicare under a spouse’s work record. You may even be able to get it under a former spouse’s work record. A child can get Medicare under a parent’s work record.

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Besides Medicare, how is home dialysis and training covered?

Most health plans pay for home dialysis and training. If your insurer won’t approve home dialysis or training, the doctor, dialysis clinic, or ESRD Network may be able to convince your plan to cover it. Once your insurer knows that people who choose home dialysis do as well or better than those on in-center dialysis and that home dialysis may be cheaper, it will probably cover these services.

Besides private health plans, Medicare, Medicaid, Veterans Health Benefits, TRICARE, and some state kidney programs pay for dialysis, too.

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When does Medicare start if I take it?

If you don’t start training for self-dialysis (at home or in-center) Medicare won’t start until the first day of the third full month of dialysis. If you start self-dialysis training before then, Medicare can start the first of the month dialysis started.

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How does Medicare pay for dialysis?

Medicare Part B covers dialysis you do at a clinic or at home. If Medicare is your primary payer, after you meet the annual deductible Medicare Part B will pay 80% of allowed charges. Other insurance may pay all or part of what Medicare does not pay.

If you have an employer plan, it will pay first for the first 30 months you’re eligible for Medicare. Your clinic can bill Medicare after your employer plan.

Medicare takes $1.50 a week from what it pays your dialysis clinic to pay for ESRD Network services. ESRD Networks collect data on dialysis, monitor the quality of care in dialysis clinics, and help resolve patient complaints.

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What is Medicare’s new bundled payment system?

Before 2011, dialysis clinics billed Medicare separately for dialysis and for ESRD-related drugs and lab tests. A new law required Medicare to start paying dialysis clinics a single rate that “bundles” dialysis treatments, ESRD-related drugs, and ESRD-related lab tests. Clinics could choose if they wanted Medicare to pay them under the new bundled rate or to move into the bundled payment over time. Most clinics chose to receive bundled payment starting January 1, 2011. By January 1, 2014, Medicare will pay all clinics under the bundled payment system.

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Will Medicare’s bundled payment affect me?

You are only affected if Original Medicare is your primary payer. If you have a Medicare Advantage plan, Medicaid, VA, TRICARE, or other insurance, you may not be affected.

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How does this change affect payment for home dialysis?

Before January 1, 2011, you could choose to have your home dialysis services under two different payment Methods. If you chose Method I, the dialysis clinic trained you, provided the dialysis machine (if needed) and supplies, and the staff saw you monthly in home dialysis clinic. The clinic billed Medicare for these services.

If you chose Method II, your clinic trained you and staff saw you monthly in clinic. The supply company you chose provided your dialysis machine and supplies and billed Medicare for them.

Starting January 1, 2011, supply companies can no longer bill Medicare. If you still get your machine and supplies from a supply company, it must bill your clinic. Your clinic must bill Medicare under the bundled payment rules and pay the supply company.

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Will my clinic charge more under bundled payment?

Medicare has paid dialysis clinics based on a patient’s age and size for some time. Under bundled payment, Medicare adjusts the base rate for dialysis if you’re a new dialysis patient or you have certain health problems that may increase your clinic’s cost to treat you. The rate is also adjusted for wages in the area or if your clinic only treats a few patients each year.

Since the new bundled rate now includes ESRD-related drugs and labs, the 20% after Medicare pays may be more or less. If you have other insurance, it may pay all or part of that 20%.

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Should I take Medicare if I have employer coverage?

When choosing whether to sign up for Medicare Part A and B or Part A alone, be aware:

• Having Medicare protects your right to get COBRA later if your company must offer it.
• Having at least Medicare Part A the month of transplant protects your right to have Part B pay for anti-rejection drugs after a transplant when you have Part B.
• If you sign up for Medicare Part A and waive Part B when you have an employer plan, you will pay more for Part B premium later unless:
  • You waive both Part A and Part B when first offered Medicare.
  • You disenroll from Medicare A and repay Medicare any claims it has paid. You cannot do this if you do qualify for Medicare due to age or disability too.
• You can avoid a gap in coverage by signing up for Part B in time for it to take effect July 1 before your employer plan starts to pay second (enroll January–March).
• Your clinic can bill Medicare after your employer plan pays or for Medicare covered things your employer plan doesn’t cover.
• Your clinic or anyone that “accepts assignment” (Medicare pays directly) can’t charge you anything if your employer plan pays at least 100% of Medicare’s allowed charge.

See Chapter 3 of the Medicare Secondary Payer Manual.

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How do employer plans and Medicare work together to pay for home dialysis?

Your dialysis billing staff should confirm that your health plan pays for home training and home dialysis. If not, your physician and dialysis staff should work to get your plan to cover training, equipment, supplies, and follow-up support. Your ESRD Network may also help advocate for you.

If you have a health plan sponsored by an employer (even if you pay the full premium) when you start dialysis, it will still pay first even if you sign up for Medicare. However, Medicare will start paying first after 30 months. The clock starts ticking from the date that you could have taken Medicare whether you took it or not. After 30 months, your employer plan may refuse to pay primary benefits so you need to have Medicare Part B in place to pay dialysis by then.

You and your clinic should know whether your insurance has a limit on lifetime benefits or a limit for kidney-related services. Hospital bills and clinic fees are high and can wipe out your health insurance benefits, leaving you with no coverage for dialysis, drugs or other health needs. Having part of these costs paid by Medicare can make your lifetime benefits last longer.

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How does Medicare pay for home training under the new payment system?

If you start home training during the first 4 months of dialysis, Medicare will pay your clinic the bundled base rate with any allowed adjustments. It will not pay extra for home training during this 4-month period. If you start training later, your clinic can charge Medicare more for each training day. The added charge is about the cost of nurse’s pay for one hour even though the home training nurse will spend several hours each training day with you.

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How does Medicare pay clinics for my home dialysis machine, support equipment, and supplies?

Medicare’s composite rate includes expenses to install home dialysis equipment for home HD or CCPD, including:

• Delivery to the home of equipment needed to do CCPD or HD.
• A system to purify water for HD.
• Plumbing or electrical work to tie the equipment into existing plumbing and electrical systems (but not rewiring the room where the CCPD or HD machine is located or installing plumbing to the room).
• Testing the CCPD or HD equipment to be sure it is working correctly.

The clinic must provide all supplies and equipment you need for what Medicare pays. Supplies include such things as alcohol wipes, sterile drapes, gloves, telfa pads, and bandages. Equipment includes such things as scales and manual blood pressure monitors. The clinic must provide support equipment such as blood and heparin pumps, an air bubble detector, a water treatment system for HD, and a basic recliner that does not rock, swivel, heat or vibrate if you need it to change position to relieve low blood pressure. The clinic must provide some drugs used during dialysis, such as injectable and topical anesthetics and heparin.

Under bundled payment the clinic must provide certain ESRD-related injectable and/or oral drugs to manage anemia and to keep bones healthy. You may have had to use Part D to get some of these in pill form at your pharmacy. Now your dialysis clinic has to provide them as part of the bundled payment.

The clinic must also provide support services. This includes time to talk with the nurse, dietitian and social worker while you’re in training, when you come to clinic visits or are at home.

See Chapter 11 §10 and §50 of the Medicare Benefit Policy Manual.

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How many sessions will Medicare cover for home hemodialysis training?

Medicare covers up to 25 home HD training sessions that usually last 5 hours. This payment is for staff time, supplies, routine labs, and training materials. A clinic may train 3 or more days a week. Clinics can train some patients to do the entire treatment themselves. Others may need a home dialysis partner who is trained to assume most tasks.

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How many home HD treatments will Medicare cover?

Medicare will routinely pay for up to three HD treatments a week. Medicare may pay for more if your doctor gives Medicare a medical reason why you need extra treatments. If you have other insurance, it may pay for extra treatments that Medicare denies.

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How many sessions will Medicare cover for PD training?

Medicare routinely pays for up to 15 training days for CAPD or CCPD. This payment is for staff time, supplies, routine labs, and training materials.

See Chapter 8 §50.8 of the Medicare Claims Processing Manual.

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Will Medicare pay for re-training?

Medicare will pay for retraining in certain cases. If you change your type of home dialysis, you get a new machine you don’t know how to use, you need a new helper, or your physical or mental status changes, Medicare will pay for retraining.

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How does Medicare pay for PD treatments when it is the primary payer?

Medicare pays for PD on a daily basis. Medicare pays the same for a week of PD as it does for a week of HD. The daily rate is the same no matter whether you use a cycler or how many CAPD exchanges you do. If Medicare is your primary payer, it still pays 80% of the allowed rate minus $1.50 for each week of PD to pay for ESRD Network services.

See Chapter 8 §80.4 of the Medicare Claims Processing Manual.

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Will Medicare pay for a home helper if I need one?

No. Medicare does not cover the services of home dialysis helpers. If a clinic provides a helper, it cannot report that expense on the cost report form it files with Medicare at the end of the year. Most people use a family member or friend as their helper. If you hire a helper, you may want to check other insurance policies to see if they will cover this cost and/or talk with your tax advisor about deducting what you pay as a medical expense.

If you get Social Security disability checks and hire a home dialysis helper so you can work, keep records of what you pay and show them to Social Security every month you work. Social Security can deduct what you pay for a helper before comparing what you make from work with the amount you are allowed to make while getting disability checks. You may be able to work, get disability checks, and pay for your helper. Working may help you get other health insurance to pay your medical bills, plus have money to pay for other needed and desired expenses.

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If I hire a home dialysis helper, will Medicare still consider me to be a home (self-care) patient?

Yes. Whether you or a helper do most tasks for your dialysis, the treatment itself is considered home (or self-care) dialysis.

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If I cannot do home dialysis for a while, can I keep my machine, and will Medicare pay for it?

Medicare will pay for home PD or HD machine for up to 3 months if you are temporarily:

• Unable to do home dialysis because of a health problem.
• Without a home dialysis partner.
• Away from home, but intend to return there.
• Doing in-center dialysis while awaiting an expected transplant.

See Chapter 11, Section 50.2 of the Medicare Benefit Policy Manual.

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What kind of support for my home dialysis should I expect my clinic to provide?

Medicare expects your clinic to provide support services to:

• Visit you in your home as needed to monitor how well you are adapting to home dialysis.
• Develop a plan of care with you and your physician, nurse, dietitian and social worker.
• See you at clinic visits regularly and see or consult with you by phone when you have problems.
• Do ESRD-related laboratory tests.
• Monitor your dialysis equipment and supplies.
• Test your water as needed for home HD.
• Keep your medical record up-to-date so your care can be coordinated with others as needed.

See Chapter 11 §50.6 of the Medicare Benefit Policy Manual.

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Can I keep my job?

Home dialysis is much more “work friendly” than in-center dialysis. You can arrange your dialysis schedule around your work schedule. If you do home HD or CCPD, you can do that after work or while you are sleeping. That leaves your workday free. If you do CAPD, your clinic can help you inform your employer about how you can do a CAPD exchange at work. All you need is a clean and private place where you can wash your hands (or use alcohol-based hand gel) and do your connection without being exposed to germs. Some patients have done exchanges in their car. Others go home for lunch.

There are a number of benefits to keeping a job:

• You can keep your same income to pay your bills.
• It keeps you busy and helps you feel like you’re making a contribution.
• As long as your employer plan is primary, the bundle of services will not apply to you.
• You may have coverage through your employer plan for things that Medicare does not cover, like vision or dental services or even more extra dialysis treatments.
• If your employer plan is primary and pays more that Medicare allows, you should not have to pay your employer plans’ deductibles and coinsurance or copays if you have Medicare Part B, too.
• Your employer plan and Medicare Part D (if you have it) can coordinate payments if you use a drug store that will bill both. Part D follows the same rules for who pays first.

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Will Medicare pay if I travel with home dialysis?

Medicare Part B will pay for dialysis inside the U.S. and its territories. This includes American Samoa, American Virgin Islands, Guam, Northern Mariana Islands, and Puerto Rico. If you give the company enough time, it may ship your supplies to you inside the U.S. You may be able to take some supplies and your machine (if you use one) if you will not be gone long or if you have enough room to transport them (van, truck, camper, trailer) when you travel.

Patients say arranging travel when doing home dialysis is less stressful than scheduling in-center dialysis when traveling. However, if you must do in-center dialysis when you travel:

• Make plans as far in advance as possible.
• Be flexible about shift times.
• Be prepared in case the clinic has to change your day or time.
• Ask your dialysis team how to adjust your diet and fluids if you will get less dialysis.
• Ask how to take prescribed drugs if you’ll be crossing time zones.

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Who can explain my insurance coverage and dialysis billing to me?

The billing staff at your dialysis clinic should be able to explain your bill and what, if anything you owe. Your social worker should be able to explain what Medicare covers and how Medicare works with other insurance. You should be able to find out about your other coverage by looking at your policy or your plan’s website or by calling customer service. If you have Medicaid, talk with your Medicaid case worker.

See Medicare Coverage of Kidney Dialysis and Kidney Transplant Services for basic information about Medicare and other coverage.

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Who can help me if I have problems paying my bills for premiums or healthcare?

If you’re having problems paying your premiums, medical bills or following your prescribed treatment, talk with your social worker. Do not drop any insurance without talking with your social worker. If you drop your health insurance, you may never get it back which could lead to even more stress. Your social worker may know sources of help.

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