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How costly is kidney failure treatment?
Kidney failure treatment—hemodialysis, peritoneal dialysis, and kidney transplantation—is costly, and most people need financial help. The average cost to Medicare per person in 2011 was1
- almost $88,000 for hemodialysis, a treatment for kidney failure that filters blood outside the body
- more than $71,000 for peritoneal dialysis, a treatment for kidney failure that uses the lining of a person’s abdominal cavity as a filter
- almost $33,000 for a transplant, surgery to place a healthy kidney from someone who has just died or a living donor, usually a family member, into a person’s body
Financial help is available from the Federal Government and other sources. In 1972, the U.S. Congress passed a law that allows most people with kidney failure coverage by Medicare.
Health care providers often bill private health plans for additional costs. States and other sources may also help. A person can live years with kidney failure, so getting help to pay for treatment is important.
Some terms listed here have many meanings; only those meanings that relate to the financial and medical aspects of kidney failure and its treatment are included. Read more about additional terms in Kidney Disease Pages.
coinsurance: an amount a person may still need to pay after a deductible for health care. The amount is most often a percent, such as 20 percent.
coordination period: if a person has more than one health plan, a coordination period is used to figure out which plan pays first and for how long. For example, if a person has an employer group plan and Medicare, the employer group plan is the first payer for the first 30 months the person is eligible for Medicare.
copay (or copayment): an amount a person may have to pay for health care. A copay is often a set fee. A person might pay $10 or $20 for a health care provider’s visit or prescription.
deductible: an amount a person must pay for health care or prescriptions before the health plan(s) will pay.
dialysis: the process of filtering wastes and extra fluid from the body by means other than the kidneys. The two forms of dialysis are hemodialysis and peritoneal dialysis. See also “hemodialysis” and “peritoneal dialysis.”
ESRD (end-stage renal disease): the legal term for permanent kidney failure. Renal means kidney.
hemodialysis: a treatment for kidney failure that filters wastes and extra fluid from the body. Hemodialysis uses a machine outside the person’s body to circulate a person’s blood through a filter, called a dialyzer.
kidney transplant: surgery to place a healthy kidney from someone who has just died or a living donor, usually a family member, into a person’s body to take over the job of the failing kidney.
network: a group of health care providers that gives members a discount. In some plans, health care and prescriptions are paid only if received from a network provider.
out of network: health care providers who are not in a plan’s network. In some health plans, health care and prescriptions cost more if received from these providers.
peritoneal dialysis: a treatment for kidney failure that uses the lining of a person’s abdominal cavity to filter blood.
premium: an amount a person must pay periodically—monthly or quarterly—for Medicare, other health plan, or drug plan coverage.
primary payer: the health plan that pays medical bills first, before bills can be sent to a secondary payer.
secondary payer: the health plan that pays medical bills second, after the primary payer has paid its portion.
social worker: a person who is trained to help people solve problems in their daily lives, especially people with disabilities or low incomes. A social worker may help with financial and employment issues. Dialysis clinics and transplant centers must have a social worker to help their patients.
What is Medicare?
Medicare is a federal insurance program that pays health care costs for eligible people who are
- age 65 or older
- under age 65 with certain disabilities
- of any age with ESRD
How can a person get Medicare for kidney failure?
To get Medicare for kidney failure, a person must meet two conditions:
- Be on dialysis or have a kidney transplant for ESRD
- Have paid enough taxes—or be the spouse or child of someone who has—through
- Social Security
- Railroad Retirement Board
- Government employment
What health plans does Medicare offer?
Three main types of Medicare health plans are available:
- Original Medicare has three parts:
- Part A (hospital) covers inpatient care, kidney transplantation, skilled nursing home residence, and hospice care. Part A has no premium for those who have paid enough Medicare taxes. A premium is an amount a person must pay periodically—monthly or quarterly—for Medicare, other health plan, or drug plan coverage. Part A does have a deductible, an amount a person must pay for health care or prescriptions before the health plan will pay. A person must pay a daily amount for hospital stays that last longer than 60 days.
- Part B (outpatient) covers most dialysis treatments and supplies, health care provider fees, and anti-rejection medications for transplant. Part B has a monthly premium based on a person’s income. Rates change each year. After a person pays the deductible each year, Part B pays 80 percent for most covered services as a primary payer. The billing staff of the service provider—hospital or clinic—can calculate how much a person will owe.
- Part D (medications) has a premium and covers some medications. Private insurance companies offer different Part D plans approved by Medicare. Costs and coverage vary by plan. A person who has few assets and earns less than 150 percent of the federal poverty level may qualify for extra help to pay Part D premiums and medication costs. The current-year guidelines can be found at www.aspe.hhs.gov/poverty or by calling Social Security at 1–800–772–1213. Information and applications for Part D plans can be found at www.medicare.gov. A person can also apply for Part D with an insurance company that sells one of these plans.
- Medicare Advantage plans, also called Part C, are sold by insurance companies. Medicare must approve Medicare Advantage plans. Each Medicare Advantage plan must cover Part A and Part B services and may cover other services, too. Medicare Advantage plans may have Part D medication coverage. If not, a person can buy a Part D plan separately. Medicare Advantage plans are not all the same. A person with failing kidneys who is thinking of choosing a Medicare Advantage plan should ask about the rules of the plan. The rules may specify which health care providers or hospitals a person may use. The plan may require a referral from a primary care provider to see a specialist. The plan may not cover medical expenses incurred during travel. How much a person has to pay out-of-pocket each year will vary by plan. People who have a Medicare Advantage plan cannot have a Medigap plan to help pay out-of-pocket costs. See the section on Medigap.
Four types of Medicare Advantage plans are available:
- health maintenance organizations (HMOs)
- preferred provider organizations (PPOs)
- private fee for service plans
- special needs plans for certain groups
Those already on dialysis cannot join most Medicare Advantage plans. However, a person who had a Medicare Advantage plan before kidney failure can keep the plan. In some regions, special needs plans are designed for those on dialysis. A person can call 1–800–MEDICARE (1–800–633–4227) to learn if region-specific special needs plans are available for those on dialysis.
Other Medicare health plans are for certain groups, such as frail people living in the community, and people with multiple chronic illnesses and include hospital and medical coverage. Some pay for prescribed medications, too. Some are partially financed and administered by state health insurance programs—called Medicaid. The plans include the following:
- Medicare Cost Plans are HMOs, like the ones offered as Medicare Advantage plans, only out-of-network providers are paid as if the policy holder had original Medicare.
- Program of All-Inclusive Care for the Elderly (PACE) combines medical, social, and long-term care services for frail people who live and get health care in the community.
- Medicare Innovation Projects are special projects that test improvements in Medicare coverage, payment, and quality of care.
More information about Medicare Cost Plans and Demonstration or Pilot Programs can be found on the state Medicaid website at www.medicaid.gov or by calling 1–800–MEDICARE (1–800–633–4227). State Medicaid offices can provide more information about PACE. See the section on Medicaid.
Where can a person enroll in Medicare?
A person can apply for Medicare online at www.ssa.gov or at a local Social Security office. Social Security’s toll-free number is 1–800–772–1213, TTY 1–800–325–0778. A person can call to set up a time to meet with someone at a local office and apply.
When does Medicare start for people with ESRD?
A person with ESRD can apply for Medicare at the start of dialysis or at the time of a kidney transplant. The Medicare start date depends on the type of treatment:
- Home dialysis, including peritoneal dialysis and hemodialysis at home. Medicare can start the first month of dialysis only if a person trains for home dialysis.
- Kidney transplant. Medicare can start the same month as the transplant. In some cases, Medicare could start up to 2 months earlier if the patient is admitted to the hospital and the transplant is delayed. For example, if a patient is admitted to the hospital for a transplant in March and the transplant is delayed until May, payment still begins in March. A transplant financial counselor can provide more information.
- In-center dialysis. Medicare will not start until the fourth month of in-center dialysis. For example, if a person starts dialysis in a clinic in July and does not train for home dialysis, Medicare will not start to pay until October 1.
|First month of dialysis
||Second month of dialysis
||Third month of dialysis
||Fourth month of dialysis. Medicare coverage begins.|
When does Medicare end for people with ESRD?
Medicare continues for as long as a person is on dialysis and pays a premium, even for people who have jobs. Medicare will end for the following two reasons:
- Kidney failure is the only reason a person had Medicare and the person gets a kidney transplant. If the new kidney works and the person no longer needs dialysis, Medicare ends 3 years after the transplant surgery.
- A person’s kidneys get better and the person no longer needs dialysis. Medicare will end 12 months after a person stops dialysis, unless the person returns to dialysis or gets a transplant within those 12 months. Medicare will not end if the person is eligible because of age or disability.
How does Medicare pay if a person has other health insurance?
The rules for which plan pays first depend on which other health insurance a person has.
|Type of Insurance Plan
||Who Pays First|
|Individual plan—not provided by an employer
||Medicare always pays first. An individual plan always pays second.|
|Employer or union group plan
||With kidney failure, the employer or union group plan pays first for 30 months* after a person is eligible for Medicare because of kidney failure. The 30-month clock starts whether the person enrolls in Medicare or not. However, the person will eventually have to enroll in Medicare. After the 30 months, Medicare pays first. The employer or union group plan may pay all or part of the rest.|
*This time period is called the “Medicare secondary payer coordination period.”
Having Medicare Part B plus another health plan can limit what a person pays out-of-pocket for health care. In some cases, Medicare can limit how much a health care provider charges for services. If a person does not have Part B, the health care provider or dialysis clinic can bill the individual or group health plan and the person at a much higher rate. The person may have to pay what the plan does not pay.
In some situations, a person who has other insurance may be able to save money by not enrolling in Part B until the 30-month coordination period is over. The person would not have to pay the Part B premiums during that period.
Should a person with other insurance wait to start paying for Part B?
- YES, if: A person’s plan pays 100 percent of all health care costs during that time.
- If a person waits to enroll in both Part A and B, enrollment for both can happen at any time.
- If a person takes Part A—waiting to start Part B—the person can only enroll once a year from January 1 through March 31 and Part B will not start until July 1. A person should enroll in Part B in time to prevent a gap in coverage. For example, if the 30-month coordination period ends April 30, an employer or union group plan can stop paying first on May 1. If a person enrolled in Part B by March 31, Part B will not start paying first until July 1. The person will have large bills for May and June.
- NO, if: The person has to pay yearly deductibles, copays, or coinsurance, which are fees not covered by the insurance plan. Medicare may or may not pay those fees. However, having Medicare limits what a dialysis clinic can charge. The premium for Part B usually costs less than paying deductibles, copays, or coinsurance.
Where can I get more information about Medicare’s kidney failure treatment coverage?
These booklets from Medicare offer more information about Medicare’s kidney failure treatment coverage:
- Medicare Coverage of Kidney Dialysis & Kidney Transplant Services
- Medicare for Children with End-Stage Renal Disease
When does an employer or union group plan start to pay?
An employer or union group plan may help pay treatment and prescribed medication costs under the following circumstances:
- Before Medicare starts to pay for dialysis, the employer or union group plan may cover most or all costs.
- During the 30-month coordination period, the employer or union group plan pays the larger part of the costs first, and then Medicare pays its portion of the remaining costs.
- After the 30-month coordination period is over, Medicare pays the larger portion first, and then the employer or union group plan pays its portion of the remaining costs.
People with kidney failure should read their health insurance policy carefully to make sure it covers kidney failure treatment. If they have questions about their benefits, they should ask their insurance agent or employer benefits counselor.
What other federal programs can help?
The following federal programs can help cover the cost of kidney failure treatment:
- Social Security Disability Insurance (SSDI). SSDI is a federal insurance plan that pays a monthly amount to people who cannot work. People earn SSDI work credits when they pay Social Security taxes. A person must have enough credits based on age to qualify. Then, if an illness or injury prohibits a person from working for at least a year, SSDI payments may be an option. A chart shows how many work credits a person needs at www.socialsecurity.gov/retire2/credits3.htm.
- Supplemental Security Income (SSI). SSI is a federal safety net program that pays a monthly amount to disabled children and adults who earn little and have few assets. A person who gets SSI may be able to get food stamps and Medicaid, too.
More information about both SSDI and SSI and how to apply can be found at www.ssa.gov or by calling 1–800–772–1213, TTY 1–800–325–0778.
What state programs can help?
State programs such as Medicaid, Medigap, and Medicare Savings Programs are funded in part by the Federal Government. However, states provide the services and decide who receives help.
Medicaid. Medicaid is a state program for those with low incomes and few assets. Each state runs its own program. The Federal Government requires that Medicaid programs cover a specific set of services; however, states can choose to cover more services in addition to the ones required. A person may have Medicaid alone or Medicare and Medicaid. If a person has both types of coverage, Medicare pays first and Medicaid pays second. Medicaid may pay for things Medicare does not. A person can apply for Medicaid at a city or county Department of Social Services office. A social worker can explain a state’s Medicaid program and help a person apply. More information about Medicaid can be found at www.medicaid.gov.
Medigap, also known as Medicare supplement. A Medigap plan can help pay what Original Medicare does not pay for covered services. Insurance companies sell Medigap coverage. People who have a Medicare Advantage plan cannot also have a Medigap plan.
For people who are 65 and older, federal law says that in the first 6 months a person has Part B, companies cannot deny an application or limit payment for anything Original Medicare covers based on the person’s health. Some states make insurance companies sell at least one Medigap coverage plan to those under 65 with Medicare. State insurance offices can explain the plans in their state. Local offices can be found by clicking on a map at www.naic.org/state_web_map.htm.
Medicare Savings Programs. Some states may pay Medicare premiums, deductibles, and coinsurance if a person has low income and few assets. A city or county Department of Social Services can determine whether a person is eligible.
Kidney-specific state assistance programs. Some states use state funds to help pay for specific kidney-related costs. A dialysis or transplant clinic social worker or a social worker in a local Department of Social Services can help a person determine if a state has a kidney program.
State Health Insurance Assistance Program (SHIP). SHIPs get money from the Federal Government to give free health insurance advice to those with Medicare. A person who needs more health insurance should talk with a SHIP counselor or a social worker.
What programs can help special populations?
Many programs can help specific populations such as U.S. veterans; military service members, retirees, and families; American Indians and Alaska Natives; children; people with disabilities; job seekers with kidney failure; kidney transplant recipients; and living organ donors.
For U.S. veterans, the U.S. Department of Veterans Affairs (VA) can help pay some health costs. Veterans can see if they qualify and apply online at www.va.gov/healthbenefits. A veteran can learn more at a local VA hospital or by calling 1–877–222–8387. Some VA hospitals provide dialysis. Others contract with dialysis clinics to give veterans better access to treatment. The VA also has its own network of transplant centers.
Military Service Members, Retirees, and Families
A person may be able to get TRICARE—the health care program serving uniformed service members, retirees, and their families worldwide—if that person is
- an active duty service member
- a military retiree
- a family member of an active duty service member or military retiree
- a member of the National Guard/Reserves on active duty for 30 days
- a family member of someone who is in the National Guard/Reserves on active duty for 30 days
TRICARE for Life is a specific TRICARE plan that offers secondary coverage for people who have Medicare Part A and Part B.
Information about TRICARE and phone numbers for its four regions can be found at www.tricare.mil.
American Indians and Alaska Natives
The Indian Health Service may help members of federally recognized American Indian or Alaska Native tribes. More information is available on the Indian Health Service website at www.IHS.gov. An American Indian or Alaska Native may also be eligible for help from public, private, and state programs.
The Children’s Health Insurance Program (CHIP) gives free or low-cost Medicaid to children whose parents earn too much for Medicaid, though not enough to pay for a health plan. CHIP may also provide assistance to parents. CHIP is a federal and state program. More information can be found at www.insurekidsnow.gov or by calling 1–877–543–7669.
People with Disabilities
A person can find state and local help for people with disabilities at www.disability.gov. On this website, a person can learn more about civil rights, community life, education, emergency planning, work, health, housing, technology, and transportation. A social worker can refer a person to federal, state, and local resources.
Job Seekers with Kidney Failure
Laws such as the Americans with Disabilities Act protect people with certain disabilities, including kidney failure. A person with kidney failure may find job training and job seeking information through
- state vocational rehabilitation programs
- private employment networks that contract with Social Security to help people with disabilities get jobs
More information about Social Security work incentives, the “Ticket to Work” program, and who can help, including vocational rehabilitation programs and employment networks, can be found at www.chooseworkttw.net.
Kidney Transplant Recipients
The United Network for Organ Sharing (UNOS) has a website called Transplant Living at www.transplantliving.org/before-the-transplant/financing-a-transplant/. Read more about UNOS in Treatment Methods for Kidney Failure: Transplantation.
Living Organ Donors
The National Living Donor Assistance Program may help those who want to donate an organ, though cannot afford to. Donors should let the transplant center know they want to apply for help to pay travel and living costs. More information about this program can be found at www.livingdonorassistance.org.
The Federal Government, some state governments, and private companies give donors medical leave. Some states give tax deductions or credits to living donors.
What private organizations can help?
Private organizations include charities and foundations. A few exist specifically to help people with kidney disease and kidney failure, such as the
- American Kidney Fund. The American Kidney Fund gives small grants to U.S. dialysis and transplant patients based on need. The American Kidney Fund has grants to help pay health plan premiums. A social worker can help a person apply for assistance. The American Kidney Fund depends on donations, so there may be times when funds are low. More information can be found at www.kidneyfund.org.
- National Kidney Foundation. Local National Kidney Foundation offices may help with nutrition, transportation, medications, and scholarships. A social worker can help a person apply for assistance. The National Kidney Foundation depends on donations, so there may be times when funds are low. More information can be found at www.kidney.org or by calling 1–800–622–9010.
How can a person save money on medications?
Medicare recommends the following ways to save money on medications:
- Ask a health care provider or pharmacist about generic and lower-cost medications.
- Ask charities for help.
- Look into Medicaid and other state medication programs.
- Apply for Part D “extra help” from Social Security.
- Research patient assistance programs. A person will need to fill out a form to apply. Forms ask about income and health plan(s). A social worker may be able to help fill out the forms if needed. The following patient assistance programs may help people who cannot afford their medications:
- State Pharmaceutical Assistance Programs are available in 22 states and one territory. More information is available at www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx.
- The Partnership for Prescription Assistance website at www.pparx.org lists more than 475 programs that help pay for medications. Many of these programs are provided by the drug companies that produce medications. People can find programs and apply for help by calling 1–888–477–2669.
- NeedyMeds is a nonprofit group that helps people find programs that help pay for medications. The NeedyMeds website at www.NeedyMeds.org allows the user to search a list of programs by medication or manufacturer name. Some of the forms to apply are online.
- RxAssist has a website at www.rxassist.org that provides information about drug company programs, state programs, discount drug cards, copay help, and more.
Points to Remember
- Kidney failure treatment—hemodialysis, peritoneal dialysis, and kidney transplantation—is costly, and most people need financial help.
- In 1972, the U.S. Congress passed a law that allows most people with kidney failure coverage by Medicare.
- A social worker is a person who is trained to help people solve problems in their daily lives, especially people with disabilities or low incomes. A social worker may help with financial and employment issues. Dialysis clinics and transplant centers must have a social worker to help their patients.
- Medicare is a federal insurance program that pays health care costs for eligible people.
- Having Medicare Part B plus another health plan can limit what a person pays out-of-pocket for health care.
- People with kidney failure should read their health insurance policy carefully to be sure it covers kidney failure treatment. If they have questions about their benefits, they should ask their insurance agent or employer benefits counselor.
- State programs such as Medicaid, Medigap, and Medicare Savings Programs are funded in part by the Federal Government. However, states provide the services and decide who receives help.
- State Health Insurance Assistance Programs (SHIPs) get money from the Federal Government to give free health insurance advice to those with Medicare.
- Many programs can help specific populations such as U.S. veterans, American Indians, children, and people with disabilities.
- Laws such as the Americans with Disabilities Act protect people with certain disabilities, including kidney failure.
- A person with kidney failure may find job training and job seeking information.
- The United Network for Organ Sharing (UNOS) has a website called Transplant Living at www.transplantliving.org/before-the-transplant/financing-a-transplant/.
- Private organizations include charities and foundations. A few exist specifically to help people with kidney disease and kidney failure.
- Patient assistance programs may help people who cannot afford their medications.
Hope through Research
The National Institute of Diabetes and Digestive and Kidney Disease’s (NIDDK’s) Division of Kidney, Urologic, and Hematologic Diseases supports programs and studies to help improve treatment for those with kidney disease and kidney failure. The Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease (MADRAD) study is looking at the role malnutrition plays in the high death rates of people on dialysis. The study will focus on racial differences in survival of people on dialysis to understand why African Americans and Hispanics fare better than non-Hispanic whites. Investigators hope that the findings will help improve survival in all dialysis patients and possibly in people with other chronic diseases. MADRAD is funded under National Institutes of Health (NIH) clinical trial number NCT01415570.
Clinical trials are research studies involving people. Clinical trials look at safe and effective new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. To learn more about clinical trials, why they matter, and how to participate, visit the NIH Clinical Research Trials and You website at www.nih.gov/health/clinicaltrials. For information about current studies, visit www.ClinicalTrials.gov.
For More Information
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244–1850
Phone: 1–800–MEDICARE (1–800–633–4227)
American Association of Kidney Patients
2701 North Rocky Point Drive, Suite 150
Tampa, FL 33607
Phone: 1–800–749–2257 or 813–636–8100
American Kidney Fund
11921 Rockville Pike, Suite 300
Rockville, MD 20852
Email: firstname.lastname@example.org or email@example.com
The Council of Nephrology Social Workers
c/o National Kidney Foundation
30 East 33rd Street
New York, NY 10016
Phone: 1–800–622–9010 or 212–889–2210
c/o Medical Education Institute, Inc.
414 D’Onofrio Drive, Suite 200
Madison, WI 53719
Phone: 1–800–468–7777 or 608–833–8333
Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication was originally reviewed by Thomas Dudley, Maria Ciccanti, Eva Fung, Emerson Carvalho, and Kelly Anderson, Centers for Medicare & Medicaid Services; Leslie Pionke, M.S.W., Inova Transplant Center, Fairfax, VA; and Cindy Cornejo, M.S.W., DaVita Dialysis Clinic, Fairfax, VA. Beth Witten, M.S.W., A.C.S.W., L.S.C.S.W., Medical Education Institute; Dori Schatell, M.S., Medical Education Institute; and Amy E. Witten, B.A., Missouri Kidney Program’s Center for Chronic Kidney Disease Education, reviewed the updated version of the publication.
You may also find additional information about this topic by visiting MedlinePlus at www.medlineplus.gov.
This publication may contain information about medications and, when taken as prescribed, the conditions they treat. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your health care provider for more information.
About the Kidney Failure Series
The NIDDK Kidney Failure Series includes booklets and fact sheets that can help the reader learn more about treatment methods for kidney failure, complications of dialysis, financial help for the treatment of kidney failure, and eating right on hemodialysis. Free single printed copies of this series can be obtained by contacting the National Kidney and Urologic Diseases Information Clearinghouse.
National Kidney Disease Education Program
3 Kidney Information Way
Bethesda, MD 20892
Phone: 1–866–4–KIDNEY (1–866–454–3639)
The National Kidney Disease Education Program (NKDEP) is an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, U.S. Department of Health and Human Services. The NKDEP aims to raise awareness of the seriousness of kidney disease, the importance of testing those at high risk, and the availability of treatment to prevent or slow kidney disease.
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.
This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.
NIH Publication No. 14–4765
Page last updated March 5, 2014