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...everything you need to know about doing dialysis at home.
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Patients have reported a number of benefits related to home dialysis, including:
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.
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.
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.
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.
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.
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.
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.
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%.
When choosing whether to sign up for Medicare Part A and B or Part A alone, be aware:
See Chapter 3 of the Medicare Secondary Payer Manual.
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.
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.
Medicare’s composite rate includes expenses to install home dialysis equipment for home HD or CCPD, including:
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.
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.
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.
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.
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.
Yes. Whether you or a helper do most tasks for your dialysis, the treatment itself is considered home (or self-care) dialysis.
Medicare will pay for home PD or HD machine for up to 3 months if you are temporarily:
See Chapter 11, Section 50.2 of the Medicare Benefit Policy Manual.
Medicare expects your clinic to provide support services to:
See Chapter 11 §50.6 of the Medicare Benefit Policy Manual.
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:
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:
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.
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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