Paying for dialysis is possible.

In this article, we examine the financial issues associated with paying for dialysis:  What are the costs of dialysis and related treatments, and what types of insurance cover these treatments?  We also look at some of the financial issues of kidney transplantation.

Costs

In the U.S. today, most dialysis patients are eligible for Medicare.

As shown in this chart, in 2010 per person Medicare costs of end stage renal disease (ESRD) were: $87,561 for a hemodialysis patient, $66,751 for a peritoneal dialysis patient, and $32,914 for a kidney transplant patient.  Note that these figures specify total Medicare cost per ESRD patient for that year.  This cost includes not just dialysis itself but also other medical care needed by the patient. Dialysis represented less than half of an average ESRD patient’s Medicare cost.  [Required notice:  The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government. ]

Note also that Medicare does not cover the full cost of treating ESRD (see below).

Insurance issues

ESRD treatment can be very costly. Furthermore, many patients develop ESRD due to other chronic conditions like diabetes and hypertension; the treatment of those conditions must be paid for too. The complexity of the U.S. health care system makes paying for all needed treatment a complex undertaking.  This article is only a general introductory guide.

Your social worker can help you navigate the various parts of the U.S. health care system.  Tell him or her about your health conditions, the kinds of treatments you will be needing, and any other needs such as transportation to the dialysis center, nursing care, etc.  Also discuss your financial situation, including what types of health care coverage you have.  Your social worker is skilled in finding various forms of financial assistance.

Background

In 1965, Medicare was enacted as a Federal program to provide health insurance to all persons age 65 and older.

In 1972, Public Law 92-603 was enacted.  One of its provisions extended Medicare coverage to ESRD patients under the age of 65.

In 1978, Public Law 95-292 was enacted.  It extended Medicare coverage to all ESRD patients regardless of age.  Public Law 95-292 also authorized the formation of ESRD Network Organizations.  These ESRD networks act as liaisons between the Centers for Medicare and Medicaid Services (CMS) and the dialysis providers.   They collect data to help administer the national Medicare ESRD program. At the present time, there are eighteen regional ESRD networks.

You can get Medicare if you are on dialysis and one of the following three criteria is true:  You have worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee; or you are already getting Social Security or Railroad Retirement benefits; or you are the spouse or dependent child of a person who meets one of the first two criteria.

Medicaremedicare-logo

Most dialysis patients join Original Medicare.  It pays for the cost of dialysis and related treatment after a deductible is met.  Your providers are reimbursed by Medicare for each service rendered (except for any co-payments for which you will continue to be responsible).

Inpatient dialysis (i.e., that which takes place in a hospital) is covered under Medicare Part A.  Medicare Part B covers your regular dialysis in any Medicare-certified dialysis center.  Medicare Part B also covers medical tests, self-care hemodialysis training and home dialysis.  Medicare Part B will also cover training in home dialysis for both you and your partner (if you have one).

You are eligible for Medicare Part A without paying any premiums, if you paid Medicare taxes while you were working.  If you qualify for Medicare Part A, then you should also qualify for Medicare Part B.  However, you will need to apply for Medicare Part B, and you will probably have to pay a monthly premium.  You can also choose to join Medicare Part D which covers prescription drugs.  For Medicare Part D coverage, you will need to pay a premium.

Medicare will generally pay 80% of the cost of covered medical services; you will be responsible for paying for the remaining 20% (your coinsurance).  But the average cost of your ESRD treatment may be so high that even paying your coinsurance can represent a significant financial burden.  You may need to find additional sources of coverage; see below.

Some Medicare recipients choose Medicare Advantage as an alternative to the traditional Medicare fee-for-service arrangement.  Medicare Advantage plans are private insurance plans that are run under contract to Medicare.  Such plans can be fee-for-service plans, health maintenance organizations (HMOs), preferred provider organizations (PPOs), etc.   However, Medicare Advantage is available only to ESRD patients who already had Medicare Advantage before being diagnosed with ESRD, or who have had a kidney transplant.

As an alternative to Original Medicare, you may be able to join a Medicare Special Needs Plan (SNP) if this is available for ESRD patients in the state where you live.  An SNP is a special type of Medicare Advantage plan that covers patients with certain severe or disabling illnesses, such as ESRD.  These plans provide the same coverage as Medicare Part A and Part B, plus Medicare prescription drug coverage.  SNPs are not available in all states.  You can check the Medicare Plan Finder website to see if any such plans are available to you.

Medicare also pays most of the cost of getting a kidney transplant.  This includes hospital care for the live kidney donor if you have one, or the cost of finding a suitable cadaveric kidney.   The remaining amounts that you are responsible for paying are listed here.

Medicare will also pay 80% of the cost of the anti-rejection (immunosuppressant) drugs you will be taking after your transplant—but only for the first 36 months, unless you are disabled or at least 65 years old.  These drugs are very expensive.

Other coverage

Unless you are affluent, you may find that paying your coinsurance—20% of the cost of dialysis or 20% of the cost of post-transplant immunosuppressant medication—represents a major financial burden.   And Medicare coverage of immunosuppressant medication ends 36 months after kidney transplant.  Thus, if you had some other form of coverage prior to being diagnosed with ESRD, it may be beneficial for you to retain that coverage even after qualifying for Medicare coverage.  If you had no other coverage, it may be beneficial to you to seek out other sources of coverage besides Medicare.  Your social worker can help you find other coverage.   Here are some possibilities.

Private insurance: If you already have private health insurance from employment or union membership (either yours or your spouse’s), then consider keeping that health insurance even after you have qualified for Medicare.  Besides paying for more of your treatment beyond what Medicare will pay, private insurance may also pay for your immunosuppressant drugs after your Medicare coverage has ended.  Ask your insurer just what they will cover.

If you do not have private insurance at this time, you can check with private insurers to see if you might still be eligible for some private insurance policy.  The Affordable Care Act (ACA; nicknamed “ObamaCare”) bans health insurance companies from turning you down due to a pre-existing condition, effective 2014.  ACA has also made available a webpage to search for public and private insurance options that might meet your needs.

“Medigap”: Medicare recipients who are at least 65 years old can purchase Medicare Supplement Insurance (“Medigap”) coverage from a private insurer.  Medigap helps pay your share of medical expenses not covered by Medicare, such as Medicare coinsurance and copayments.  However, some private insurers may not offer Medigap policies to you if you have ESRD and are younger than 65 years of age, unless you live in a state whose laws require it.  (Currently, 26 states require Medigap insurers to offer policies to ESRD patients under 65 years of age.)

Medicaid: Medicaid is a Federal program to help states provide health care coverage for low-income Americans.  If you already have Medicaid, you may choose to retain it even after qualifying for Medicare.  If you do not have Medicaid coverage, you can still apply for it.  You may be eligible for Medicaid coverage if you meet the income and resource limits set by the state in which you reside.

Dual coverage

With two insurers, one acts as your primary insurer and the other acts as your secondary insurer. Your primary insurer pays your health care providers first.  Then your secondary insurer pays those health care providers for part or all of what the primary insurer did not cover (subject to the secondary insurer’s own rules on what it covers).

If you retain private health insurance in addition to Medicare, then for your first 30 months of treatment for ESRD, your private insurance is your primary insurer and Medicare is your secondary insurer.  After that, Medicare becomes primary and your private insurer becomes secondary.

Unlike a private insurer, Medicaid never pays first for services that Medicare covers.

In 2010, 45% of new hemodialysis patients were covered only by Medicare; 14% had dual Medicare/Medicaid coverage; and 15.6% were covered by a Medicare HMO provider.

Social Security Disability Insurance (SSDI)

If you are unable to work, you may be eligible for Social Security Disability Insurance (SSDI).   This is a program that provides financial aid to anyone who is unable to work due to a disabling condition like ESRD—as long as he or she has paid Social Security taxes long enough.

If you are on SSDI and return to work at some point, SSDI allows you a trial work period (at least nine months) to see if you can stay employed despite your disability.  Past that point, however, if you earn more than $1,010 per month, your SSDI benefits may be stopped.

Summary

Paying for dialysis treatments is doable. You should never feel crushed or overwhelmed because of all the option available to you including; medicare, medicaid, private insurance, dual coverage, and SSDI. Talk to your social worker and learn what avenue is best for you. With Medicare and Medicaid dedicating resources to ESRD treatment and most states maintaining their own assistance programs specifically for paying for dialysis you should have no shortage of options. Learn all you can and pick the one that’s best for you.