Paying for Treatment
- What are the benefits of home dialysis?
Patients say that home dialysis has many benefits for them—and research studies agree. These benefits include:
- Having more energy, fewer ups and downs, and sleeping better.
- Eating and drinking more of what you love.
- Fitting in dialysis around your life instead of squeezing your life in around a clinic's schedule.
- Taking (and paying for) fewer medicines.
- Keeping your job, income, and health plan.
- Having a lower infection risk, since you avoid germs in the clinic.
- Protecting your access, since only you or a care partner use it.
- Setting your own rules at home. You can eat and drink, have friends over, watch TV or listen to music without earphones, play games with family, etc.
- Knowing more and feeling in control.
- Getting Medicare on day 1 when dialysis starts (if you start training before your 4th month of treatment). With in-center treatments, Medicare doesn't start until after the 4th month. This delay can cost you thousands of dollars.
- Saving money by going to the clinic just once or twice a month instead of 3 times a week.
- Spending less time in the hospital and living longer (with some types of home hemodialysis).
- How is dialysis paid for?
Most US citizens (about 93%) can get Medicare when they start dialysis or have a transplant. To get Medicare, you need to have worked enough and paid Medicare payroll taxes. If you haven't worked 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.
If you have an employer plan, it will pay first ("primary") for the first 30 months that you can get Medicare (whether or not you take it). Medicare will pay second during those 30 months if you have it. After 30 months, it switches. Medicare pays first and your other plan pays second.
Medicare Part B covers dialysis. The most Medicare Part B will pay is 80% of Medicare's allowed charge for dialysis—at home or in a clinic—after you meet your annual Part B deductible. You do need a second plan to pay the rest. This might be health plan through work, TRICARE, a private health plan, Medigap, Indian Health Services, etc. If you have no health plan and have a very low income and few assets, you may be able to get Medicaid (state medical assistance) in your state.
- How do I know what medicare coverage choice is best for me?
Medicare has created a simple tool - The Out of Pocket Cost Estimator - to help you see how your coverage choices impact your costs. You can also compare your current costs with different coverage options.
- Besides Medicare, how is home dialysis and training covered?
Nearly all health plans will pay for home dialysis and training. If yours won't, the doctor, clinic, or ESRD Network may be able to convince your plan to cover it. People who do home dialysis tend to stay out of the hospital and use fewer prescribed drugs, which saves health plans a lot of money. Once they understand this, they tend to approve home treatments.
- When does Medicare start if I take it?
Good question—and this can be very important for you. Timing is everything. If you do dialysis in a clinic, Medicare will not start to pay until the first day of your 4th month of dialysis. You will need to pay any bills your health plan does not cover. If you don't have a health plan, you could owe tens of thousands of dollars for those first 3 months.
But, if you start training for any home treatment (or self-care in a clinic) before the first day of your 4th month of dialysis, Medicare will start on day 1. This can save you tens of thousands of dollars for dialysis and other health care that Medicare will cover.
For example, let's say you start dialysis on June 1. But, you don't start self-dialysis training until after September 1. Medicare will start on September 1. But, if you start home training any time before September 1, your Medicare can be backdated to June 1. If you had a hospital stay, access surgery, or other health care the month you start dialysis, those could be covered by Medicare Part A or Part B.
Use our Medicare Calculator to see when medicare will start based on when you started training.
- What is Medicare's bundled payment system?
Under a 2008 law, Medicare must pay clinics one rate that covers most of the costs of a dialysis treatment. This rate that took effect on January 1, 2011 "bundles" the treatments, some drugs, and certain lab tests. Although clinics could phase into this new system, most chose to start getting paid this way on January 1, 2011. By January 1, 2014, Medicare will pay all dialysis clinics under this system.
- Will my clinic charge me more under bundled payment?
Medicare has paid dialysis clinics based on each patient's age and size for some time. With bundled payment, Medicare pays almost $100 more per treatment, since some drugs and lab tests are now in the bundle. Medicare pays 51% more for the first 120 days of dialysis if you are a new patient. Medicare also pays your clinic more if:
- You have certain costly health problems
- Wages are higher in your area
- Your clinic only treats a few patients each year
You may pay less, because some costly drugs are in the bundle. But the 20% left after Medicare pays may be more than it was under the old payment system. If you have other insurance, it may pay all or part of that 20%.
- Should I take Medicare if I have employer coverage?
In most cases, yes. Here's why:
- If you have Medicare Part B, your clinic (or anyone that "accepts assignment" which means that Medicare pays them directly, can't charge you anything if your employer plan pays at least 100% of Medicare's allowed charge. This can save you much more than the Part B premiums would cost you. If you don't have Part B, your clinic may charge you or your employer group health plan as much as ten times the Medicare rate.
- Your clinic can bill Part B after your employer plan pays. And, your clinic can bill Part B for care your employer plan doesn't cover that Medicare does cover.
- Having Medicare Part A or Part B protects your right to get COBRA later, if your company must offer it. Getting Medicare after you have COBRA allows your company to stop COBRA.
If you are thinking about taking Medicare Part B when you have an employer plan, ask your state insurance department if you can still get a Medigap plan later.
See Chapter 3 of the Medicare Secondary Payer Manual.
- Should I take both Medicare Part A and Part B?
Medicare Part A (hospital care) is free when you qualify for it. But, Part B (outpatient care, like dialysis) has a premium. Taking Part B is optional. To help you choose whether to take Part A and B or just Part A, here are two key facts:
If you sign up for Part A and waive Part B when you have an employer plan,
you can only enroll in Part B from January 1 to March 31 each year.
And, you may have to pay more for your Part B premium when you
- You waive both parts when first offered Medicare
- You disenroll from Part A and repay any claims Medicare has paid. (You can't do this if you qualify for Medicare due to age or disability, too.)
- Having at least Part A during the month of a transplant protects your right to have Part B pay for anti-rejection drugs after a transplant (when you have Part B).
If you take Part A but not Part B, you can avoid having a gap in coverage. Sign up for Part B by March 31 so Part B is in effect on the July 1 before your employer plan stops paying first.
- If you sign up for Part A and waive Part B when you have an employer plan, you can only enroll in Part B from January 1 to March 31 each year. And, you may have to pay more for your Part B premium when you do enroll unless:
- How do employer plans and Medicare work together to pay for home dialysis?
Your clinic billing staff will need to make sure that your health plan pays for training and home dialysis. If not, your doctor and care team can work to get your plan to cover training, equipment, supplies, and follow-up support. Your ESRD Network may also help advocate for you.
An employer group health plan (EGHP) will pay first ("primary") for your first 30 months of dialysis. If you have Medicare, too, it will pay second ("secondary"). After 30 months, they trade places. Medicare will be primary. At 30 months, your EGHP may refuse to pay first, so you need to have Medicare Part B to pay for dialysis by then.
You and your clinic need to know if your EGHP has a limit on lifetime costs, or costs for kidney disease care. Hospital bills and clinic fees are high and can wipe out your health plan. If this happens, you would have no coverage for dialysis, drugs or other health needs. Having part of these costs paid by Medicare can make your lifetime limits last longer. In 2014, the Affordable Care Act (ACA) stops most health plans from setting limits on what they will pay per year or for a lifetime. Learn more about the ACA and health plan limits.
- How does Medicare pay for home training under the bundled payment system?
If you start home dialysis (or in-center self-care) training before your 4th month of dialysis, Medicare will pay your clinic 80% of the bundled rate for your care. Medicare will pay 51% more for treatments in your first 120 days of treatment, if you have it. It will not pay extra for home training during this time. The 20% you or your health plan owes will be higher, because of the 51% payment bump.
If you start training later, your clinic can charge Medicare a little 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.
- How does Medicare pay clinics for my home dialysis machine, support equipment, and supplies?
Medicare's payment to your clinic includes the cost of a home machine for HD or PD. The payment covers:
- Bringing a PD cycler or home HD machine to your home.
- A water treatment system for home HD (if needed).
- Plumbing or wiring to tie the equipment into the plumbing and wiring your home has. (It does not include rewiring the room where you will put the machine or adding plumbing to the room.)
- Testing the machine to be sure it is working.
The clinic must provide all supplies and equipment you need, for what Medicare pays, and some medicines.
Supplies include such things as:
- Alcohol wipes
- Sterile drapes
- Telfa pads (to help stop bleeding after HD)
Equipment includes such things as:
- Dialysis machine (HD or PD)
- A scale
- A manual blood pressure monitor
- Blood and other pumps for HD
- An air bubble detector for HD
- A water treatment system for HD (if needed)
- A basic recliner that does not rock, swivel, heat, or vibrate. If you do HD in bed, you don't need a recliner. Your clinic should not tell you that you have to buy a chair for HD. But, if you want heat, etc., you need to pay for those upgrades.
Medicine includes such things as:
- Injectable or topical anesthetics
In the bundled payment, the clinic must also provide you with some medicines to treat anemia and to help keep your bones healthy. You may have had to use Part D to get some of these in pill form at your drugstore. Now your clinic has to give them to you.
The clinic must also give you support services. This includes time to talk with the nurse, dietitian, and social worker while you're in training, and when you come to clinic visits or are at home.
See Chapter 11, §10 and §50 of the Medicare Benefit Policy Manual.
- How many training sessions will Medicare cover for PD?
Most people can learn to do PD in 5–10 training days. A training day can last 5 hours. Medicare pays for up to 15 PD training days. The payment is for equipment, supplies, bundled labs and drugs, staff time and training materials. With manual PD or cycler PD, you will do a few PD exchanges on each training day. Expect to do PD training each weekday until you are ready to go home.
- How many training sessions will Medicare cover for home HD?
Medicare pays for up to 25 home HD training sessions. A training session may last 5 hours. This payment is for staff time, use of the machine, supplies, bundled labs and drugs, and training materials. A clinic may train 3 or more days a week. Clinics can train some patients to do the whole treatment themselves. Others may need a partner who is trained to do some or all of the tasks.
- How many PD treatments will Medicare cover?
Medicare pays for each day that you do PD. Take or send your treatment records to the clinic so it can bill Medicare.
- How many home HD treatments will Medicare cover?
Medicare will routinely pay for up to three HD treatments a week. It may pay for more HD treatments if your doctor gives Medicare a health reason why you need more. If you have another health plan, it may pay for extra treatments that Medicare won't pay for. Make sure your clinic gets your treatment records so it can bill Medicare and other health plan the right amounts.
- Will Medicare pay for re-training?
Medicare will pay for retraining if you:
- Change your type of home treatment (e.g., from manual to cycler PD, or from PD to home HD)
- Get a new machine you don't know how to use
- Need a new helper
- Have physical or mental status changes
- Will Medicare pay for a home helper if I need one?
No. Medicare does not pay for home dialysis helpers. If a clinic provides a helper, it cannot put 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 your health plans to see if they will pay for the cost. Talk with your tax advisor about deducting what you pay as a medical expense on your taxes.
Do you get disability checks from Social Security? If you do, and you hire a home dialysis helper so you can work, keep records of what you pay. Show your records to Social Security each month that you work. They can deduct helper costs before they look at what you earn vs. how much you can earn and still get disability checks. You may be able to work, get disability, and pay for a helper. Working may help you get another health plan, plus have money to pay for other expenses.
- If I hire a home dialysis helper, will Medicare still consider me to be a home (self-care) patient?
Yes. Whether you do all or most of your dialysis or a helper does most tasks for you, the treatment itself is home (or self-care) dialysis.
- If I cannot do home dialysis for a while, can I keep my machine, and will Medicare pay for it?
Medicare will pay for a 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, §50.2 of the Medicare Benefit Policy Manual.
- 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.
- Can I do home dialysis and keep my job?
Home treatments of any kind are much more "work friendly" than in-center HD. You can fit your dialysis in around your work schedule. If you do home HD or cycler PD, you can do treatments after work or while you sleep. This leaves your workdays free. If you do manual PD, your clinic can help you tell your employer how you can do a PD 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 connect to the PD tubing without being exposed to germs. Some patients do PD exchanges in their car. Others go home for lunch.
There are a number of benefits to keeping a job:
- You can keep your income to pay your bills.
- It keeps you busy and helps you feel like you are contributing.
- While your work health plan is primary, the dialysis bundled payment will not apply to you.
- A work health plan may pay for things Medicare does not, like vision or dental care or even more dialysis treatments.
- Do you have Medicare Part B while your work health plan is primary? If your work health plan pays at least 100% of what Medicare allows, you should not have to pay your work health plans' deductibles, coinsurance, or copays.
- Your work health plan and Medicare Part D (if you have it) can coordinate payments if you use a drugstore that will bill both. This can save you money. Part D follows the same rules for who pays first.
- Will Medicare pay if I travel with home dialysis?
Medicare Part B will pay for dialysis in the 50 U.S. states and the U.S. territories of American Samoa, American Virgin Islands, Guam, Northern Mariana Islands, and Puerto Rico.
If you give your supply company a head start, it can ship your supplies to you inside the U.S. (this is free). You may be able to take some supplies and your machine (if you use one) along on a short trip, if you have enough room (van, truck, camper, trailer, boat) when you travel.
Patients say that setting up travel with home dialysis is less stressful than scheduling in-center HD. But, if you must do in-center HD when you travel:
- Plan as far ahead as you can (30–60 days is best and more at peak times, like holidays)
- Be flexible about shift times
- Don't be surprised if 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 when to take prescribed drugs if you'll be crossing time zones
- Who can explain my health plan coverage and dialysis billing to me?
The billing staff at your 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 health plans. Or, call 1-800-MEDICARE. You should be able to find out about your other health plan(s) 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 to learn more about Medicare and other health plans when you have kidney failure.
- Who can help me if I have problems paying my bills for premiums or healthcare?
If you can't pay for your premiums, medical bills or your prescribed treatments, talk with your social worker. And talk to your social worker before you drop a health plan. If you drop a health plan, you may never be able to get it back. This can lead to even more stress for you. Your social worker may know sources of help.
- Will the Affordable Care Act (ACA) help me?
If you have an employer health plan, the ACA:
- Holds costs down
- Keeps plans from dropping your health insurance when your costs are high
- Requires health plans to cover more preventive services free
- Ends caps on annual or lifetime benefit limits
Your plan may even pay you or your employer (if it pays your full premium) a rebate if it charges too high a premium based on its costs of services.
If you have Medicare, the ACA expands preventive services in Medicare Part B. It reduces how much you have to pay out-of-pocket for drugs in the Part D donut hole. You may have to pay a little more for doctors if you have Original Medicare and Medigap plans C or F to keep you from overusing physician services.
The ACA allows states to expand Medicaid to those whose income is above the current guidelines. If your state chooses to do this, Medicaid may cover you. It may be the only payer if you don't have Medicare or may pay after Medicare or other insurance.
In 2014 ACA will offer new options for health insurance through the health insurance marketplace. And, it will prevent health plans from turning you down, since you have a history of health problems. State healthcare exchanges must cover prescription drugs as an "essential health benefit." If you have Medicare for ESRD, you may be worried about losing it 36 months after transplant. With the ACA, you may now be able to re-think being tested for a transplant.