Financial Resources

Medicare is a health insurance program available for people aged 65 and older, under age 65 with certain disabilities, or of any age with end-stage renal disease (ESRD). ESRD includes permanent kidney failure requiring dialysis or a kidney transplant.

Medicare has different parts.

Medicare Part A (hospital insurance) covers kidney transplants, inpatient care in hospitals, inpatient care in skilled nursing facilities (not custodial or long-term care), hospice care, and some home health care.
Most people don't have to pay a monthly premium for Part A because they (or a spouse) paid Medicare taxes while working.

Medicare Part B (hospital insurance) covers doctors' services, outpatient hospital care, dialysis, laboratories, and other medical services that Part A does not cover, such as physical and occupational therapy. Part B also helps pay for other covered medical services and items (such as transplant medications) when medically necessary.

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 1 of each year. This amount may be higher if you do not 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 percent of the costs, so you may need other insurance to help cover the remaining costs.

When you sign up for Medicare Part B, the premium is usually taken from 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 choose to cancel it, your Medicare Part B coverage would end and you would be responsible for payment for dialysis if you don’t have other coverage. You need Medicare Part B to get the full benefits available under Medicare for people with permanent kidney failure.

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.

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.

You may enroll in Medicare Part D, which offers some prescription drug coverage. You must have Medicare Part A 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.

Private insurance frequently pays for the entire cost of treatment, less any patient responsibility, and it may pay for the 20 percent that Medicare doesn't cover or your prescription drugs. If you have group health plan coverage based on your 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 directly from an insurance company. Also, employers may pay part of the cost of the coverage.

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 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 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, they may 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.

Medicare pays for certain medications given during dialysis and for immunosuppressants to prevent rejection of a transplanted kidney. Medicare may not cover other self-administered drugs that you need.

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 that give discounts to patients without Medicare or private insurance who meet income guidelines. Talk with your doctor about patient assistance programs related to medications that they prescribe that you may be struggling to afford.

Medicaid 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 healthcare 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 with 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 one available in your state.

The U.S. Department of Veterans Affairs can help pay for ESRD treatment if you are a veteran. For more information, call the U.S. Department of Veteran's Affairs at 1-800-827-1000 or visit https://department.va.gov. If you or your spouse is retired from the military, contact the Department of Defense at 1-800-538-9552 or visit https://www.defense.gov.

These benefits from the Social Security Administration help you with daily living costs. To receive Social Security Disability Insurance (SSDI), you must be unable to work and have earned the required work credits.

You can receive Supplemental Security Income (SSI) if you don't own much and have a low income. People who get SSI are usually able to get food stamps and Medicaid. 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).

In most states, there are agencies that can help with healthcare costs that Medicare doesn't cover. Some states also have Kidney Commissions that help people pay these costs. Call your State Health Insurance Assistance Program if you have questions about health insurance.