Medicare FAQs for patientsQuestions answered below:
General Financial Information
* Who pays for dialysis?
* How soon can I get Medicare and how do I sign up?
* How does my employer group health plan work with Medicare?
* How does Medicare work?
* Who pays for my home dialysis training?
* What is Method I or Method II payment for home dialysis supplies and services?
* How can I get coverage to help pay what Medicare doesn't pay on Medicare covered services, like dialysis?
* How can I get Medigap coverage if I'm under 65?
* What happens to my Medigap plan if I get a job with health insurance?
Especially for PD Patients
* How can I get my peritoneal catheter surgery paid for?
* Will Medicare pay for my PD training?
* What PD supplies are covered by Medicare?
* How does Medicare pay for PD equipment, supplies, and support services under Method I?
* How does Medicare pay for PD equipment, supplies, and support services under Method II?
* Will my PD be paid for if I travel?
Especially for Home Hemodialysis Patients
* Will my hemodialysis access surgery be paid for?
* Will Medicare pay for my home hemodialysis training?
* Will Medicare pay for changes to my house so I can do dialysis at home?
* What will Medicare pay for if I do home hemodialysis?
* How does Medicare pay for the HHD machine, supplies, and support services under Method I?
* How does Medicare pay for the HHD machine, supplies, and support services under Method II?
* Will Medicare pay for a home dialysis recliner?
* Will my home hemodialysis be paid for if I travel?
Who pays for dialysis?
Most insurance pays for home dialysis and training. Some managed care organizations may require "prior authorization." If your insurance won't approve home dialysis or training, ask your doctor, dialysis clinic, or ESRD Network to go to bat for you. Once your insurance knows that people who choose home dialysis do as well or better than those on in-center dialysis, and that home dialysis may be cheaper, it will probably cover these services.
Besides private insurance, Medicare, Medicaid (state medical assistance for people with low incomes), Veterans Administration, and Indian Health Service will help pay for dialysis, too. Find out what your plan covers and how much you will owe. If you need help paying for dialysis, talk with your dialysis social worker or the clinic admissions or billing office.
How soon can I get Medicare and how do I sign up?
If you are 65 or older or disabled, you may already have Medicare. You can also get Medicare at any age if you have kidney failure and you worked enough to qualify for Social Security, or you qualify under a spouse's or parent's work record. Call (800) 633-4227 to find out if you qualify.
You can sign up for Medicare with a CMS-43 form (Application for Health Insurance Under Medicare for Individual with Chronic Renal Disease). Your local Social Security office and some dialysis clinics have this form.
When the time for dialysis comes, your dialysis clinic will ask you to fill out and sign a CMS-2728 form that tells Social Security that you started dialysis. If you start home dialysis training in your first 3 months of dialysis, Medicare will start paying on the 1st day of the month you started dialysis. Otherwise, there is a 3-month waiting period before Medicare will start.
How does my employer group health plan work with Medicare?
If you have an employer group health plan (EGHP), it will pay first and Medicare will pay second for 30 months from when you could have Medicare (the "coordination of benefits" period). When you start home training and home dialysis during this 30 month period, your EGHP pays first and Medicare pays second. So, if your EGHP does not pay the whole charge, your clinic can bill Medicare for the balance. After 30 months, Medicare will pay first and your EGHP will pay second.
Dialysis clinics and doctors often charge an EGHP more than what Medicare approves, so the payments they receive during this time will be higher than when Medicare becomes primary after 30 months. This means that when you keep your EGHP coverage, your clinic should be willing to work with you if you want to choose a home treatment.
Be sure that your clinic or any home dialysis supply company you choose to work with accept Medicare assignment. This means they will bill Medicare for you and they agree not to bill you for any cost that is over Medicare's allowed charge.
How does Medicare work?
Medicare for kidney failure pays for any care that Medicare covers, not just kidney treatments. Medicare has two parts:
* Part A pays for hospital care, including transplant. Part A is free if you have worked enough time and paid into the Social Security and Medicare trust funds. If you are 65 or older and have not worked enough, you can pay a premium to get Medicare Part A.
* Part B pays for doctors and outpatient care, like dialysis. There is a monthly premium for Part B. Social Security takes the premium out of your monthly Social Security checks. If you don't get a Social Security check, you will get a bill every 3 months to pay Medicare Part B premiums. Remember you must pay your premiums to keep your Medicare benefits.
Premiums you pay are for the next quarter. You may not get your first premium notice right away so set aside the amount you will owe so you can pay the bill when it is due.
Who pays for my home dialysis training?
Your health insurance and/or Medicare will pay for home dialysis training, whether you want to learn PD or home hemodialysis. The number of training days Medicare will pay for depends on whether you want to learn PD or home hemodialysis. We'll talk more about this under PD and home hemodialysis.
What is Method I or Method II payment for home dialysis supplies and services?
When you do home dialysis and have Medicare, you must choose how you want to get your supplies and equipment. You make this choice on the CMS-382 (ESRD Beneficiary Selection) form. Each year, you have one chance to change the Method you choose. Your choice will start the next January 1. If you have other insurance instead of Medicare, this will not apply to you until you have Medicare.
* If you choose Method I, your dialysis clinic will install and maintain your machine (if you need one), provide supplies, and support you through regular clinic visits, phone calls, and sometimes home visits. Your clinic will charge the Medicare approved amount for these services. Medicare will pay 80% of this charge. Since dialysis clinics accept Medicare assignment, your clinic cannot bill you or your insurance more than the 20% balance that's left.
* If you choose Method II, your dialysis clinic will only bill for support services—visits with the nurse, social worker, and dietitian at the clinic or in your home. It will help you get your machine (if needed), and supplies directly from a supply company. The supply company will install and maintain your machine, deliver your supplies, and bill Medicare. Medicare allows supply companies to charge more under Method II for machines and supplies than clinics can charge under Method I. Medicare will pay 80% of the higher amount it lets a supply company charge, plus 80% of the amount it lets your clinic charge for support services. Because these charges are higher, the 20% you or your insurance will owe could be higher if you choose Method II.
How can I get coverage to help pay what Medicare doesn't pay on Medicare covered services, like dialysis?
Insurance companies sell Medicare supplement plans or "Medigap" plans that help pay Medicare deductibles and coinsurance. In most states, these plans follow a model set up by the National Association of Insurance Commissioners (NAIC). The NAIC labels plans with the letters A to L. Every "A" plan is the same. The same is true of every "L" plan, etc. This makes it easy to shop for a plan, because all you have to do is compare the premiums and make sure your healthcare providers accept that plan. Companies are not required to sell all plans in your state. Three states do not follow the NAIC model—Massachusetts, Minnesota, and Wisconsin.
Federal law requires that if you are 65 or older and sign up for Medicare Part B, you have a 6 month open enrollment period to buy a Medigap plan—even with kidney failure. You can't be turned down or charged more than other 65 year olds. The company must count any months you had other insurance toward your 6-month waiting period for pre-existing conditions. If you developed kidney failure and signed up for Medicare Part B before age 65, when you turn 65, you will have another 6 month open enrollment period to buy a Medigap plan. Medicare coverage counts toward the 6 month waiting period, so if you had Medicare for 6 months, you won't have a waiting period for pre-existing conditions. If you signed up for Part B when you were under 65, you'll get a new Medigap open enrollment period when you turn 65. If you have questions, you can contact your state insurance department.
* Click here for more information on Medigap coverage.
How can I get Medigap coverage if I'm under 65?
If you're under 65 and have kidney failure or another disability, some states require companies to sell plans to you. Companies do not have to offer all plans to those under 65 as they do to those over 65. And, they may only allow those under 65 to join during an open enrollment period. States that require companies to sell to those with Medicare due to disability or kidney failure are California, Connecticut, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Texas, Washington, and Wisconsin. See the Medicare website for more information on Medigap coverage.
* 2006 Choosing a Medigap Policy: A Guide to Health Insurance for People With Medicare
What happens to my Medigap plan if I get a job with health insurance?
If you get a job with health insurance, you can suspend your Medigap plan. If you lose that coverage later, you have 90 days to ask for your Medigap plan again with the same coverage and premiums as before, and your plan must cover any pre-existing conditions. See the Medicare website for more information.
* 2006 Choosing a Medigap Policy: A Guide to Health Insurance for People With Medicare
How can I get my peritoneal catheter surgery paid for?
Charges for a PD catheter include the hospital, surgeon, medicines, supplies, labs, and other tests. How much you will owe depends on your insurance policy. Your health insurance and/or Medicare will probably cover most of the cost of getting a PD catheter. Ask for the most experienced PD catheter surgeon that your plan will cover.
If you have no other insurance and need Medicare to cover the cost of your catheter, plan to get your catheter placed early in the month you start dialysis. Start PD training before the third full month you're on dialysis. Then you can ask for Medicare to start the first day of the month you started dialysis.
Example:
1. Your doctor tells you that you need to start dialysis right away and explains your treatment options. You decide to do PD, but you have to start hemodialysis (HD) first, because you don't have enough time to let a PD catheter heal.
2. On March 15, you have surgery to put in a catheter for HD, and ask the surgeon to put in your PD catheter at the same time. Your first HD treatment is March 17.
3. You tell your doctor that you need Medicare to start as soon as possible. He or she calls the home training nurse, and you start PD training on April 15.
4. Your clinic tells Social Security that you started home PD training. Social Security backdates your Medicare to March 1 to help pay for your doctor, surgeon, hospital and dialysis charges.
Will Medicare pay for my PD training?
Medicare will pay for up to 15 days of training for either CAPD or APD, and most people learn how to do PD in a week or two. In some cases, Medicare will pay for more days if your doctor provides a good reason (e.g., you are blind or have other health problems that make PD harder to learn).
If you have an employer group plan as your first payer, Medicare can be billed for any balance left over after your insurance pays.
What PD supplies are covered by Medicare?
Under either Method I or Method II Medicare covers PD supplies such as:
* A PD machine, if you use one
* Manual blood pressure cuff and stethoscope
* IV stand
* Dialysate heater
* Dialysate solution
* Tubing
* Ancillary supplies such as gloves, syringes, tape
* A start-up kit that includes such things as a scale, thermometer, scissors, clamps, etc., if it's charged as part of your dialysis equipment
The dialysis clinic must give you any antibiotic your doctor prescribes for peritonitis, but Medicare will not pay for it because they believe the rate they pay clinics is enough to cover antibiotics. Medicare does pay extra for EPO (Epogen® or Aranesp®). Medicare will pay for EPO shots if you have anemia, and you or your helper have been trained to give it, and you know your diet and recognize high and low blood pressure. Your clinic will ask you to track any EPO you give yourself and to bring your records with you.
Sometimes you may need to come into the dialysis clinic to get IV Iron or other drugs to treat your anemia or bone disease.
How does Medicare pay for PD equipment, supplies, and support services under Method I?
When you choose Method I, your dialysis clinic provides your equipment and supplies. Regular maintenance for a PD machine is included if you have one. You can call or meet with the nurse, social worker, and dietitian and come to clinics at no extra charge.
Support services includes your nurse checking your exit site, changing the transfer set, watching you do an exchange and reviewing your PD technique, and tracking any peritonitis you have. Your clinic will bill Medicare for each day that you do PD at home or when you travel. Expect your clinic to ask you to keep records of your daily treatments for your nurse to review and for Medicare billing.
How does Medicare pay for PD equipment, supplies, and support services under Method II?
When you choose Method II, you contract with a supply company to provide the supplies and equipment your doctor prescribes for you. Medicare covers the same equipment and supplies through a Method II supplier as it does through a dialysis clinic under Method I. The only difference is that Medicare allows the Method II supplier to charge more.
Under Method II, your dialysis clinic only bills you for support services at a rate that Medicare allows. This rate is intended to pay for time you spend with the dietitian, social worker, and nurse at regular clinic visits. When your nurse checks your exit site, changes your transfer set, watches you do an exchange and reviews your PD technique, and tracks any peritonitis you have, these are all included in the "support services" charge.
Will my PD be paid for if I travel?
As long as you don't need a clinic or hospital, your home clinic (under Method I) or your supply company (under Method II) can bill just as if you were doing PD at home.
Talk to your insurance before you leave about what you need to do to be covered in case you need to go to a clinic or hospital while you're traveling. Medicare will pay for dialysis or a hospital stay anywhere in the U.S. and its territories. Some insurance or managed care companies will not pay if you are outside their coverage area unless your problem is life threatening. If you have Medicare as a secondary payer and your primary insurance denies a claim, a dialysis clinic or hospital can bill Medicare.
Will my hemodialysis access surgery be paid for?
It depends. If you have an employer group health plan (EGHP), it may pay for your surgery, but you will need to be sure you go to a hospital that is covered by your health plan. Ask for the most experienced access surgeon your health plan has to offer.
If you have no EGHP and Medicare will be your primary payer:
1. Have your access surgery in the same month you start dialysis
2. Start your home hemo training before the first day of your third full month of dialysis
This way, your hospital and doctors can bill Medicare for your access surgery and all your dialysis treatments and training days.
Example:
1. You learn that your kidneys have failed and you need to start dialysis right away. Your doctor explains your treatment options. You decide you want to do hemodialysis (HD). Your doctor schedules you to get an access on March 15. You have your first dialysis treatment on March 17.
2. You let your doctor know that you need Medicare to start as soon as possible, and that you'd like to do home HD. He or she calls the home training nurse, and you start HD training on May 28.
3. Your dialysis clinic notifies Social Security that you have started home training. Social Security will backdate your Medicare to March 1 to help pay for your doctor, surgeon, hospital and dialysis charges.
Will Medicare pay for my home hemodialysis training?
Medicare will pay your dialysis clinic the rate it normally pays for in-center dialysis plus $20 for every day of your home hemodialysis training. This extra $20 is to cover staff time, supplies, a training manual, and certain lab tests.
Most people can learn how to do home hemodialysis in 6 to 8 weeks. Medicare assumes that most patients can be trained in 3 months of 3-5 hour training sessions a week.
If you have an employer group plan as your first payer, Medicare can be billed for any balance left over after your insurance pays.
Will Medicare pay for changes to my house so I can do dialysis at home?
Medicare will pay to:
* Have your dialysis machine delivered, installed, and tested for use.
* Obtain and hook up water purification tanks to your plumbing.
* Hook up the machine to existing power lines.
* Provide reverse osmosis (RO) or deionization (DI) tanks to purify your water, but not both.
Medicare will not pay for home improvements like installing plumbing or wiring into the room where you'll dialyze if it is not already there. Usually, this costs a few hundred dollars or less.
What will Medicare pay for if I do home hemodialysis?
Under either Method I or Method II, Medicare covers:
* The home hemodialysis machine and all the parts you need to do dialysis
* An IV pole
* Either deionization (DI) or reverse osmosis (RO) systems to purify water (but not spare DI tanks)
* Doctor-ordered carbon filters to get rid of harmful chemicals in your water.
* A basic recliner—no swivel, rocker, heat, or vibrate
* A meter to measure the conductivity of your dialysis solution
* Manual blood pressure cuff and stethoscope
* Enough dialyzers for 3 treatments a week
* Enough blood tubing for 3 treatments a week
* Dialysate and supplies to test it
* Chemicals to sterilize your machine
* Saline
* Dialysis needles
* Heparin to thin your blood
* Needles and syringes
Although Medicare does not normally pay for alcohol, betadine, topical anesthetic, tape, gauze, or bandages, if these are included in a kit of covered supplies for no extra charge, Medicare will pay for them.
How does Medicare pay for the HHD machine, supplies, and support services under Method I?
Under Method I, your dialysis clinic provides those things you need to do your dialysis. Your supplies will be delivered to your home storage area. Your clinic bills Medicare for each day you do dialysis, so they will ask you to keep and return copies of your treatment records to back up the clinic's charges. Medicare pays for 3 hemodialysis treatments a week. If you need more treatments, your doctor must justify them or Medicare will not pay for them.
Medicare pays for dialysis using a composite rate payment, which covers all dialysis related supplies and certain laboratory tests. The amount is based on whether your clinic is owned by a hospital or is free-standing, and on where your clinic is located. The composite rate is intended to cover supplies and labor costs. Medicare pays as much for home hemodialysis as for in-center dialysis. If you have an employer group health plan, the clinic will probably charge your employer group health plan more than it charges Medicare, no matter what type of dialysis you do.
How does Medicare pay for the HHD machine, supplies, and support services under Method II?
Under Method II, your clinic will help you to contract with one supply company. After the supply company receives your doctor's prescription, it will deliver the equipment and supplies you need for dialysis to your home storage area. The supply company will bill Medicare's durable medical equipment regional carrier (DMERC) for your supplies.
Will Medicare pay for a home dialysis recliner?
The Medicare Claims Processing manual that addresses home dialysis states this:
The following items are paid for and must be furnished under the composite rate. The facility may furnish them directly under arrangements, to all of its home dialysis patients. If the facility fails to furnish (either directly or under arrangements) any part of the items and services covered under the rate, then the facility cannot be paid any amount for the part of the items and services that the facility does furnish.
* Medically necessary dialysis equipment and dialysis support equipment;
* Home dialysis support services including the delivery, installation, maintenance, repair, and testing of home dialysis equipment, and home support equipment;
* Purchase and delivery of all necessary dialysis supplies;
* Routine ESRD related laboratory tests; and
* All dialysis services furnished by the facility's staff.
See Section 80.1 of the Medicare Claims Processing Manual, Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims.
Will my home hemodialysis be paid for if I travel?
Ask your clinic or supply company whether you can take your machine with you when you travel. Some may discourage taking a machine when you travel because of risk of damage and need for expensive repairs. If your machine is portable enough for you to travel and you have permission from your clinic or supply company, as long as you don't need to go to a clinic or hospital, your home clinic (under Method I) or your supply company (under Method II) can bill Medicare as if you were doing hemodialysis in your home.
Even if you take your home hemodialysis machine with you, it's always a good idea to have a backup plan for where to get dialysis if you have a problem. Make backup plans at least 30 days in advance. Hand carry your latest medical records and have a list of phone numbers—the backup clinic, your home clinic, your supply company, and your doctor.
Ask how your insurance will pay if you travel. If you have Medicare, it will pay for dialysis anywhere in the U.S. or its territories. If your primary insurance denies a claim, a dialysis clinic or hospital can bill Medicare.
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http://www.homedialysis.org/resources/medicarefaq/
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