When you become ill, you should focus on getting better. You should take the time to decide what treatments are right for you. Along with treatment decisions, there are financial decisions that must be made. You may not have money set aside for medical expenses. When you have a chronic illness that requires on-going treatment, you may be concerned about how you will afford your needed treatment. That’s why we’ve written this section for you. Once you understand the options that are available, you will be empowered to make a decision that is best for you. So, explore the options and resources presented in the following chapter. Make notes about any questions you may have. Remember, your doctor is available to help.
When you begin to seek ways to pay for your medical expenses, keep in mind that there are many options that may help pay for your dialysis treatments. Some of your options may include Medicare, private insurance, Medicaid, Social Security and, in some states, renal programs. Some of these programs are very detailed. Take time to consult with your nephrologist. He or she can guide you toward someone with the appropriate resources to help you with your medical expenses.
What is Medicare?
In 1972, Congress passed legislation making people of any age with permanent kidney failure eligible for Medicare. This health insurance program is available for people:
- Age 65 and older
- Under age 65 with certain disabilities
- Any age with End-Stage Renal Disease, sometimes referred to as ESRD. (End-Stage Renal Disease includes chronic renal failure, permanent kidney failure requiring dialysis or a kidney transplant.)
What Medicare Covers
You may have heard about Medicare and its different parts. Let’s take a look at what each part covers.
Medicare Part A (Hospital Insurance) Covers the Following:
- Kidney transplants
- Inpatient care in hospitals
- Inpatient care in skilled nursing facilities (not custodial or long-term care)
- Hospice care
- Some home health care
Medicare Part A Costs
Most people don’t have to pay a monthly premium for Part A because they (or a spouse) paid Medicare taxes while they were working.
Medicare Part B (Medical Insurance) Covers the Following:
- Doctors’ services
- Outpatient hospital care
- Dialysis
- Laboratories
- Other medical services that Part A doesn’t cover (like physical and occupational therapy)
Part B helps pay for these covered medical services and items (such as transplant medications) when they are medically necessary.
Medicare Part B Costs
Everyone must pay a monthly premium for Medicare Part B. Premium rates can change yearly. Any change in the Part B premium amount will be effective on January 1st of each year. This amount may be higher if you don’t sign up for Part B when you first become eligible. Call Social Security at 1-800-772-1213 for current premium amounts for Part B, or visit www.Medicare.gov. It is important to remember that Medicare alone pays only 80% of costs, so you may need other insurance to help cover the remaining costs.
Paying for Medicare Part B
When you sign up for Medicare Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement, or Office of Personnel Management payment. If you don’t get one of these payments, Medicare sends you a bill for your Part B premium every three months. You should get your Medicare premium bill by the 10th of the month. If you don’t get your bill by the 10th, call Social Security at 1-800-772-1213.
You must pay your Medicare Part B premium. If you don’t pay your Part B premium, or if you choose to cancel it, your Medicare Part B coverage will end. You need Medicare Part B to get the full benefits available under Medicare for people with ESRD or chronic renal failure.
How Medicare Works with Insurance
If you are eligible for Medicare only because of permanent kidney failure, your eligibility usually can’t start until the fourth month of dialysis unless you choose a method of Home Therapy and then Medicare coverage begins immediately. Therefore, if you have an insurance plan (purchased as an individual or through work), that plan will be the only payer for the first three months of dialysis (unless you have other sources of coverage as well). There are rules about whether Medicare or your insurance company will pay first. This can be discussed with your social worker once dialysis or the transplant process begins. Again, you should not drop or refuse insurance before you seek guidance from an expert as it is difficult for those with kidney disease to qualify for private insurance.
If you need more information about how Medicare works with insurance, you should get a copy of your plan’s benefits booklet and call your benefits administrator. Ask how the plan pays when you have Medicare.
Medicare Part D and Prescription Drugs
You may decide to enroll in Medicare Part D which offers some prescription drug coverage. You must have Medicare Part A in order to enroll in Medicare Part D. If you have current insurance coverage for prescriptions, you may not need Medicare Part D.
Medicare provides extra help to pay prescription drug costs for people who meet specific limits on income and resources. Resources include your savings and stocks but not your home or car. If you qualify, you will get help paying for your Medicare drug plan’s monthly premium, yearly deductible, and prescription co-payments or coinsurance. Call Social Security to see if you qualify for extra help.
Patient Assistance Programs from Prescription Drug Companies
Medicare pays for erythropoietin to treat anemia in kidney failure and for immunosuppressants to prevent rejection of a transplanted kidney. Other self-administered drugs that you need may not be covered by Medicare. If you have trouble paying for all the medications your doctor prescribes, you may qualify for assistance from private programs. Most drug manufacturers have patient assistance programs giving discounts to patients without Medicare or private insurance and who meet income guidelines.
The Partnership for Prescription Assistance provides a website that directs patients, caregivers, and doctors to more than 275 public and private patient assistance programs, including more than 150 programs offered by pharmaceutical companies. The website features an application wizard that helps you determine which programs might be available to you. The web address is www.pparx.org.
Employee or Retiree Coverage from an Employer or Private Insurance Plan
Private insurance frequently pays for the entire cost of treatment. It may pay for the 20% that Medicare doesn’t cover. Private insurance may also pay for your prescription drugs. If you have group health plan coverage based on you or your spouse’s past or current employment, or your parents’ current employment, call your benefits administrator to find out what coverage might be provided for your kidney failure. If you are eligible for coverage under the group health plan but have not signed up for it, call the benefits administrator to find out if you can still enroll. Generally, employer or union group health plans have better rates than you can get if you buy a Medigap policy yourself directly from an insurance company. Also, employers may pay part of the cost of the coverage.
Medigap (Medicare Supplement Insurance) Policies
A Medigap policy is health insurance sold by private insurance companies to help fill the “gaps” in original Medicare plan coverage like deductibles and coinsurance. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. Medigap insurance must follow federal and state laws that protect you. All Medigap policies are clearly marked “Medicare Supplement Insurance.” However, not all insurance companies will sell Medigap policies to people with Medicare under age 65. If a company does sell Medigap policies voluntarily or because state law requires it to, these Medigap policies will probably cost you more than if you were 65 or older. Medigap rules vary from state to state. Call your State Health Insurance Assistance Program for information about buying a Medigap policy if you are disabled or have ESRD. For more detailed information about Medigap policies, visit www.medicare.gov.
Medicaid
This is a joint federal and state program that helps pay medical costs for some people with limited income and resources. Medicaid programs vary from state to state. Most health care costs are covered if you qualify for both Medicare and Medicaid. Some states also have Medicare Savings programs that pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance for certain people who have Medicare and a limited income. If you are interested in these programs, ask your doctor to refer you to the appropriate person who can help you find a program that is available in your state.
Veterans’ Benefits
If you are a veteran, the U.S. Department of Veteran’s Affairs can help pay for ESRD treatment. For more information, call the U.S. Department of Veteran’s Affairs at 1-800-827-1000. If you or your spouse is retired from the military, call the Department of Defense at 1-800-538-9552 for more information.
Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI)
These benefits from the Social Security Administration help you with the costs of daily living. To receive Social Security Disability Insurance (SSDI), you must be unable to work and have earned the required number of work credits.
You can receive Supplemental Security Income (SSI) if you don’t own much and have a low income. People who get SSI usually get food stamps andMedicaid, too. To find out if you qualify for SSDI and SSI, talk to your social worker, call your local Social Security office, or call the nationwide number (1–800–772–1213).
Other Ways to Get Help
In most states there are agencies that help with some of the health care costs that Medicare doesn’t pay. Some states also have Kidney Commissions that help people pay the costs that Medicare doesn’t pay. Call your State Health Insurance Assistance Program if you have questions about health insurance.