If you have permanent kidney failure, you may be worried about paying for the expensive treatments you need.
In 1972, Congress passed legislation making people of any age with permanent kidney failure eligible for Medicare, a program that helps people over 65 and people with disabilities pay for medical care, usually up to 80 percent. Other public and private resources can help with the remaining 20 percent. Your dialysis or transplant center has a social worker who can help you locate and apply for financial assistance.
Medicare is a federally administered health insurance program for people 65 and older and people of any age with permanent kidney failure. To qualify for Medicare on the basis of kidney failure, you must
need regular dialysis
have had a kidney transplant
and you must
have paid into Social Security through your employer
worked under the Railroad Retirement Board, or as a government employee (or be the child or spouse of someone who has)
you must already be receiving Social Security, Railroad Retirement, or Office of Personnel Management benefits.
You can enroll for Medicare at your local Social Security office (check the blue pages in your phone directory to locate the office).
Medicare has two parts: Part A (hospital insurance) and Part B (medical insurance). Part B covers doctors’ services, outpatient hospital services, and many other health services and supplies. While Medicare Part A has no premiums, Part B requires you to pay premiums, deductibles, and coinsurance. Part B is voluntary. Most of the services and supplies needed by people with permanent kidney failure are covered by Medicare Part B.
You will apply for Medicare when you start dialysis treatments. Your Medicare benefits then begin the third month after the month your course of regular dialysis treatments begins. For example, if you begin receiving regular dialysis treatments in July, your Medicare coverage would start on October 1. Coverage can begin earlier if you take self-care dialysis training (for home hemodialysis or peritoneal dialysis) before the third month or have a transplant within the first 3 months.
If you’re covered by a group health plan, Medicare is a secondary payer during a 30-month coordination period. Your group health plan pays at its regular level for this period. Since you usually can’t get Medicare in the first 3 months, your group health plan is the only payer for health services. In the third month, Medicare begins to cover only that portion of your health services that isn’t covered by your group health plan. Medicare then becomes the primary payer for your health insurance claims at the end of the 30-month period.
You may wish to wait to enroll in Medicare Part A and Part B until the end of the 30-month coordination period if your group health plan will pay for all of your health care expenses. In doing so, you’ll avoid paying the Medicare Part B premium.
Enrolling in Medicare Parts A and B could help pay a yearly deductible or coinsurance payment required by some group health plans.
Contact your local Social Security office or call the nationwide toll-free number at 1–800–772–1213 if you want to apply for Medicare. Often, the social worker at your hospital or dialysis center will help you apply.
Private insurance frequently pays for the entire cost of treatment. Or it may pay for the 20 percent that Medicare doesn’t cover. Private insurance may also pay for your prescription drugs. Read your private health insurance policy carefully to make sure it covers kidney failure. Talk with your insurance agent or company benefits counselor if you have any questions about your benefits.
Medicaid is a state program. Your income must be below a certain level to receive Medicaid funds. If you aren’t eligible for Medicare, Medicaid may pay for your treatments. In some states, it pays the 20 percent that Medicare doesn’t cover. It may also pay for some of your medicines. To apply for Medicaid, talk with your social worker or contact your local department of human services or social services.
State Children’s Health Insurance Program
The U.S. Department of Health and Human Services has established the State Children’s Health Insurance Program (SCHIP) to help children without health insurance. SCHIP provides health coverage for children whose families earn too much to qualify for Medicaid but too little to afford private health insurance. Consumers can obtain information about the program by calling toll-free 1-877-KIDS-NOW (543-7669), or by checking www.insurekidsnow.gov.
Department of Veterans Affairs (VA) Benefits
If you’re a veteran, the VA can help pay for treatment or provide other benefits. Contact your local VA office for more information, or call 1–800–827–1000 to reach the national office. If you’re retired from the military, you may also call the Department of Defense at 1–800–538–9552.
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 and Medicaid, too. To find out if you qualify for SSDI and SSI, talk to your social worker or call your local Social Security office or the nationwide number, 1–800–772–1213.
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. But 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 who can show that they can’t afford the cost of their prescribed medications.
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.
National Kidney and Urologic Diseases Information Clearinghouse
3 Information Way
Bethesda, MD 20892–3580
The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1987, the Clearinghouse provides information about diseases of the kidneys and urologic system to people with kidney and urologic disorders and to their families, health care professionals, and the public. The NKUDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about kidney and urologic diseases.
Publications produced by the clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication was reviewed by Margaret Jefferson, Eve Fisher, Jackie Sheridan, and Betty Burrier, Centers for Medicare & Medicaid Services.
This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.
NIH Publication No. 07–4765