Medicare 101 for People on Home Dialysis
Article by Beth Witten, MSW, ACSW, LSCSW
One good thing about kidney failure is having help from Medicare to pay for treatment. In 1973, Medicare was extended to those with permanent kidney failure who need dialysis or a transplant and who qualify for Social Security. When you have Medicare for kidney failure, it covers care for other health problems, too.
How to qualify for Medicare
Besides needing dialysis or a kidney transplant, to get Medicare for kidney failure, you need to have work credits. You earn credits by earning money in each quarter of a year. Each year, the amount you must earn to gain a credit goes up. In 2007, you need to earn at least $1,000 in a quarter to earn a credit. (This goes up to $1,050 in 2008.) You can earn up to 4 credits a year.
The younger you are, the fewer work credits you need. If you're under 24, the most credits you would need is 6. If you're 24 through 30, you need more. By age 62, you need 40 credits. Social Security can tell you how many credits you have and how many you need. 1
Haven't worked outside the home? You may still qualify for Medicare if your spouse has worked enough. Even if you're divorced or widowed, a former spouse's credits count for your Medicare if you were married for at least 10 years—and haven't remarried before age 60.
A parent's work credits can qualify a child for Medicare, too. And, in some cases, an adult child's work credits can help a dependent parent over age 65 to qualify. (NOTE: Using someone else's work credits to get Medicare does not take any credits away from their record.)
How Medicare works
Medicare Part A (hospital care) is free if you have enough credits. There is a premium if you don't have enough credits. As long as you're on dialysis or within 36 months of a transplant, you can work and keep Part A for free. Even longer after a transplant, workers with other disabilities can keep Medicare by paying for it. Or, some states will pay their premiums.
Medicare Part B (medical) has a monthly premium. Parts A and B both have deductibles to pay before Medicare starts paying. Do you have low income and few assets? You can apply for a Medicare savings program though your state's Medicaid (or Medi-Cal in California) agency to help pay your premiums. With a low-enough income, your state will also help pay your Part A and B deductibles and the 20% Medicare co-pay.
Home dialysis and Medicare
For in-center hemodialysis (HD), Medicare will not start to pay until your third full month of treatment. This means you will have to pay any bills for hospitals, doctors, etc. that aren't paid by other health insurance. But, you can get Medicare on the first day of the month you start dialysis if you start a home training program. (NOTE: You must start to train for a home treatment before your third full month of dialysis.)
Whether you choose peritoneal dialysis (PD) or HD, you will need surgery to create an access. Unless you have other insurance, this can cost you thousands of dollars. But when you start home training before your third full month of treatment, you may be able to get Medicare backdated to pay for your access surgery.
Here's how this can work:
| Dialysis treatment choices | November (partial month of dialysis) | December (1st full month) | January (2nd full month) | February (3rd full month) |
|---|---|---|---|---|
| In-center HD |
• You have access surgery after the 1st • Your access heals and is ready to use • You have your 1st treatment |
You do in-center HD all month | You do in-center HD all month | Medicare starts on the 1st of this month |
| PD or home hemo |
• You have access surgery after the 1st • Your access heals and is ready to use • You have your 1st treatment • Medicare starts on the 1st of this month |
You do in-center HD or start PD or home HD training | Or, you start PD or home HD training this month | You are training for PD or home HD or doing home PD or HD |
What Medicare pays for at home
Many people think that if they do dialysis at home, they have to buy or rent the machine. Not true! It's the job of the dialysis center to provide your training and to give you a machine and supplies. Medicare (or your insurance) pays for the machine—you don't have to buy it.
Medicare also pays for up to 15 days to train you for PD (most people learn how in a week or two) and up to 2 months in three 5-hour training sessions a week for home HD (most people learn in much less time).
If you do PD, your clinic will supply:
- A PD cycler if you use one
- A manual blood pressure cuff
- A stethoscope
- A dialysate heater
- An IV pole
- Dialysate fluid
- Tubing
- Supplies such as gloves, tape, gauze, etc.
- A start-up kit with a scale, thermometer, scissors, clamps...
- Antibiotics for an infection
- EPO and other IV drugs
If you do home HD, your clinic will supply:
- The HD machine
- An IV pole
- Water treatment equipment
- A manual blood pressure cuff
- A stethoscope
- Enough dialyzers to do three treatments per week
- Enough blood tubing to do three treatments per week
- Dialysate and supplies to test it
- Chemicals to sterilize your machine (if needed)
- Saline fluid for flushing
- Dialysis needles
- Heparin to thin your blood
- Needles and syringes
Some home HD machines require wiring or plumbing changes. Medicare won't pay for this, but some clinics will take care of it. If not, these costs may run a few hundred dollars. Your clinic may also provide a basic recliner.
Medicare pays for three HD treatments per week. In some cases, your doctor can write a letter to Medicare and they will allow one more payment per week. This fourth payment can make it possible for a center to offer you daily home HD or nocturnal home HD more than three nights per week. Or, if you have an employer group health plan, it may pay for more treatments.
Medicare and employer group health plans (EGHPs)
Why would you want to pay extra premiums for Medicare Part B if you have an EGHP? The law is that your EGHP must pay first for 30 months. The "clock" starts when you are eligible for Medicare—whether or not you take it.
If you take Medicare, any health care provider that "accepts assignment" agrees to take 100% of Medicare's allowed charges as payment in full. This means if your EGHP pays at least as much as Medicare allows, your dialysis clinic can't bill you for more. So, having Medicare and using health care providers that accept assignment can save you thousands of dollars more than you would pay for the Part B premiums.
As a primary payer, Medicare Part B pays 80% of the Medicare allowed charge for dialysis. The other 20% can be paid by an EGHP or Medicaid (if you have it) or by a Medigap plan. Hospitals and doctors have 18 months to bill Medicare. Tell them if your Medicare is backdated.
Minimizing your dialysis costs
There are steps you can take to pay less for care related to your dialysis:
- Ask your doctors if they accept Medicare assignment. All dialysis clinics do.
- Tell your doctor, clinic, and other healthcare providers what health coverage you have and always report any changes in coverage right away.
- Apply for Medicare and ask for it to start the first date you're eligible.
- Apply for Medicaid (Medi-Cal in California) if you have limited income and assets.
- Ask the Medicaid caseworker if you qualify for a Medicare savings program to pay premiums, deductibles, and co-pays, and apply if you do.
- Ask your state insurance department if you can get a Medigap plan and apply for one. (NOTE: You will have to pay for a Medigap plan.)
- If your income is too high for Medicaid, ask your dialysis social worker if you can get help to pay your premiums from the American Kidney Fund.
Besides having control over your own treatment and schedule, choosing PD or home HD for your first treatment can save you thousands of dollars out-of-pocket each year for hospitals, doctors, and dialysis. Give home dialysis a try. You'll be glad you did!
References:
- How You Earn Credits; Social Security Administration (SSA) Pub. 05-10072; accessed January 2007.
- Employment: A Kidney Patient's Guide to Working and Paying for Treatment ; Medical Education Institute, 2003.
- Medicare Coverage of Kidney Dialysis and Kidney Transplant Services; Centers for Medicare & Medicaid Services (CMS) Pub. 10128; accessed April 2007.