Financial Help for Treatment of Kidney Failure
History of Financial Kidney Assistance
Before the development of dialysis and transplantation in the 1950s and 60s, having permanent kidney failure, also called end-stage renal disease (ESRD), was a death sentence. While life-saving, these treatment methods are expensive, and few people can afford them without assistance.
In 1972, Congress passed legislation making people of any age with permanent kidney failure eligible for Medicare, a program that helps people age 65 or older and people with disabilities pay for medical care, usually up to 80 percent. The remaining 20 percent can still pose a significant financial burden on patients. Fortunately, other public and private resources can help. Anyone with permanent kidney failure who does not have adequate insurance coverage should seek the help of a certified or licensed social worker. Every dialysis and transplant center has a social worker who can help people with kidney failure locate and apply for financial assistance. Social workers who specialize in helping kidney patients are nephrology social workers.
Patients can also enlist the assistance of the State Health Insurance Assistance Program (SHIP). The SHIP is a national program that provides free counseling and assistance to Medicare beneficiaries on a wide range of Medicare and supplemental insurance matters. Patients can find a state program by visiting www.shipusa.org.
To qualify for Medicare on the basis of kidney failure, a person must:
- require regular dialysis
- have had a Medicare-covered kidney transplant
- have paid into Social Secruity through an employer—or be the child or spouse of someone who has
- have worked under the Railroad Retirement Board, or as a government employee—or be the child or spouse of someone who has
- already be receiving Social Security, Railroad Retirement or Office of Personnel Management benefits
The Original Medicare Plan has two parts: Part A is hospital insurance, and Part B is medical insurance. Part B covers most outpatient services, including kidney dialysis, doctors’ services, outpatient hospital services and many other health services and supplies. While Part A has no premiums, most of the Part B services require premiums, deductibles and coinsurance.
Some people who are not eligible for Medicare because they have not worked at a job that pays into Social Security may still be eligible to buy Medicare coverage by paying premiums for Part A.
Starting in the late 1990s, Medicare gave recipients the option to choose a plan managed by a private insurance company that functions like a health maintenance organization (HMO) or a preferred provider organization (PPO). These plans are called Medicare Advantage, or Part C plans. In most areas of the United States, Medicare recipients with kidney failure are not eligible for the Medicare Advantage option, unless they participated in Medicare Advantage prior to kidney failure. However, a few programs, called Medicare Special Needs plans, offer coverage designed specifically for people with kidney failure. Patients should contact Medicare at 1-800-MEDICARE (1-800-633-4227) to learn more about possible programs in their area.
In 2006, Medicare added Part D, prescription drug coverage. People with permanent kidney failure are eligible but not required to enroll in Part D. When enrolling in Part D, a person chooses from a list of available plans in that person’s region. People who have employer group health plans that include prescription coverage should ask their employer whether enrolling in Part D will have any negative impact on their medical coverage. Some private plans will drop anyone who elects a Part D plan. A patient’s existing prescription coverage with an employer group plan may be as good or better than a Part D plan. Employers and unions that provide prescription drug coverage must notify Medicare enrollees each year about how their current coverage compares to Medicare’s basic prescription drug coverage. This information may come in a letter, in a notice from the group plan or in a benefits handbook. People should use this information to help in deciding whether to join a Medicare drug plan. Beneficiaries should note that a penalty may apply if they don’t join a Part D plan when they are first eligible, don’t otherwise have prescription drug coverage, and then later decide to join a Medicare program. The amount of the penalty will depend on how long the beneficiary went without prescription drug coverage before joining a Part D plan.
A person may apply for Medicare when starting dialysis treatments. Medicare benefits then begin the third month after regular dialysis treatments begin. For example, if regular dialysis treatments begin in July, Medicare coverage would start on October 1. Coverage can begin earlier if a person takes self-care dialysis training for home hemodialysis or peritoneal dialysis before the third month or has a transplant within the first 3 months.
For a person covered by a group health plan, Medicare is a secondary payer during a 30-month coordination period. The group health plan pays at its regular level for this period. Since Medicare is usually not available in the first 3 months, the group health plan is the only payer for health services. In the fourth month, Medicare begins to cover only that portion of heatlh services that is not overed by the group health plan. Medicare then becomes the primary payer for health insurance claims at the end of the 30-month period.
A person may wish to enroll in Parts A and B until the end of the 30-month coordination period if the group health plan will pay for all health care expenses. In doing so, the person will avoid paying the Part B premium.
Enrolling in Parts A and B could help pay a yearly deductible or coinsurance payment required by some group health plans.
A person can enroll in medicare at a local Social Security office listed in the blue pages in the phone directory. The nationwide toll-free number for Social Security is 1-800-772-1213, and that number can be used to schedule an appointment at a local office. More information about local Social Security offices is also available online at www.ssa.gov. Often, the social worker at a hospital or dialysis center can guide applicants through the enrollment process.
Private insurance frequently pays for the entire cost of treatment. Or it may pay for the 20 percent Medicare doesn’t cover. Private insurance may also pay for prescription drugs. People with kidney failure should read their private health insurance policy carefully to make sure it covers kidney failure treatment. They should talk with their insurance agent or company benefits counselor if they have any questions about their benefits. People who do not have private insurance can work with a social worker, nurse or a doctor to locate and apply for other sources of financial aid. SHIPs may also be a good resource.
State Disability and Employment Programs
Many state social services agencies will help with medical expenses. For people with kidney failure who want to work, many states have specific vocational rehabilitation programs to help people with disabilities train for and find a job. Local or regional offices of state government agencies are listed in the blue pages of the phone directory. Additionally, the New Freedom Initiative’s online resource for people with disabilities at www.disabilityinfor.gov has a search tool to locate state and local resources. A social worker at a hospital or dialysis center can also guide patients to community resources for vocational rehabilitation.
Medicaid is a joint federal and state program that is primarily income based. The guidelines for the program vary by state. For people to receive Medicaid funds, the value of their assets and annual income must be below a certain level. Medicaid may pay for dialysis or tansplantation if a person is not eligible for Medicare. In some states, Medicaid pays for the 20 percent that Medicare doesn’t cover. It may also pay for some medicines. Applications for Medicaid can be obtained by contacting a local human services or social services department. A nephrology social worker can provide guidance on how to apply.
State Children’s Health Insurance Program (SCHIP)
The U.S. Department of Health and Human Services has established the 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 1-877-KIDS-NOW (1-877-543-7669) or by checking www.insurekidsnow.gov.
U.S. Department of Veterans Affairs (VA) Benefits
The VA can help pay for treatment or provide other benefits for veterans. Veterans should contact their local VA office for more information or call 1-800-827-1000 to reach the national office. The number for health care benefits at the VA is 1-877-222-8387. People who are retired from the military may also call the U.S. 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 (SSA) help with the costs of daily living. To receive SSDI, a person must be unable to work and have earned the required number of work credits.
SSI is unavailable to disabled children and adults with limited income and resources. People who get SSI usually qualify for food stamps and Medicaid, too. Eligibility for SSDI and SSI is determined by the SSA office. Applications can be completed by contacting Social Security at 1-800-722-1213 or by visiting a local Social Security office. More information about SSDI and SSI is available online at www.ssa.gov.
People who qualify for SSI may also be eligible for the Ticket to Work and Self-Sufficiency program. The SSA sponsors this program to help people with disabilities, including permanent kidney failure, to train for and find a job they can perform. Participants in the program receive a voucher that can be used to receive training or placement services at a state or federal employment agency. More information is available at www.yourtickettowork.com.
Patient Assistance Programs (PAPs) from Prescription Drug Companies
Medicare Part B pays for erythropoietin to treat anemia in kidney failure and for immunosuppressants to prevent rejection of a transplanted kidney. But Part B only covers 80 percent of immunosuppressant medicine costs, which can be $2,000 a month. That means that a person who does not have additional prescription coverage will still owe $400 a month for these medicines. And other self-administered drugs may not be covered by Medicare. Also, patients should note that Medicare eligibility typically ends 36 months after a kidney transplant is received unless the patient is otherwise eligible for Medicare.
People who have trouble paying for all the medications their doctor prescribes may qualify for assistance from private programs. Most drug manufacturers have PAPs that give discounts to people who can show they can’t afford the cost of their prescribed medications. Nephrology social workers are well versed in assisting with the completion of these applications.
The Partnership for Prescription Assistance provides a website that directs patients, caregivers and doctors to more than 275 public and private PAPs, including more than 150 programs offered by pharmaceutical companies. The website features an application wizard that helps a person determine which programs might be available. The web address is www.pparx.org. Medicare has also compiled information to help beneficiaries pay pharmaceutical expenses. Visit www.medicare.gov/bridging-the-gap.asp for more information or read Bridging the Coverage Gap at www.medicare.gov/publications.
NeedyMeds is a 501(c)(3) nonprofit organization that helps people find appropriate PAPs. The NeedyMeds website provides a directory of PAPs that can be searched by a drug’s brand or generic name or by a program or company name. Applications for these programs are usually available online. The web address is www.needymeds.org.
- In 1972, Congress passed legislation making people of any age with permanent kidney failure eligible for Medicare.
- People with kidney failure should read their private health insurance policy carefully to make sure it covers kidney failure treatment. They should talk with their insurance agent or company benefits counselor if they have any questions about their benefits.
- Anyone with permanent kidney failure who does not have adequate insurance coverage should seek the help of a certified or licensed social worker or a State Health Insurance Assistance Program (SHIP).
Hope through Research
The NIDDK’s Division of Kidney, Urologic and Hematologic Diseases supports several programs and studies devoted to improving treatment for people with progressive kidney disease and permanent kidney failure, including people on hemodialysis.
- The End-Stage Renal Disease Program promotes research to reduce medical problems from bone, blood, nervous system, metabolic, gastrointestinal, cardiovascular and endocrine abnormalities in kidney failure and to improve the effectiveness of dialysis and transplantation. The research focuses on reusing hemodialysis membranes and using alternative dialyzer sterilization methods; devising more efficient, biocompatible membranes; refining high-flux hemodialysis; and developing criteria for dialysis adequacy. The program also seeks to increase kidney graft and patient survival and to maximize quality of life.
- The U.S. Renal Data System (USRDS) collects, analyzes and distributes information about kidney failure in the United States. The USRDS is funded directly by the NIDDK in conjunction with the Centers for Medicare & Medicaid Services. The USRDS publishes an Annual Data Report, which characterizes the total population of people with kidney failure; reports on incidence, prevalence, mortality rates, and trends over time; and develops data on the effects of various treatment modalities. The report, available at www.usrds.org, also helps identify problems and opportunities for more focused special research on kidney issues.
Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available and help others by contributing to medical research. For information about current studies, visit www.clinicaltrials.gov.
All the information presented is courtesy of the following organizations:
US Dept. of Health and Human Services
National Institutes of Health
National Institute of Diabetes and Digestive and Kidney Diseases
National Kidney and Urologic Diseases Information Clearing House
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