In this section:
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
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. States and other sources may also help.
Health care providers often bill private health plans for additional costs. 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.
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.
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.
Medicare is a federal insurance program that pays health care costs for eligible people who are
To get Medicare for kidney failure, a person must meet two conditions:
Three main types of Medicare health plans are available:
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:
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.
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.
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.
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:
|First month of dialysis||Second month of dialysis||Third month of dialysis||Fourth month of dialysis. Medicare coverage begins.|
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:
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.|
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?
These booklets from Medicare offer more information about Medicare’s kidney failure treatment coverage:
An employer or union group plan may help pay treatment and prescribed medication costs under the following circumstances:
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.
The following federal programs can help cover the cost of kidney failure treatment:
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.
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.
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 counseloror a social worker.
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.
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
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.
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.
A person can find state and local help for people with disabilities at www.dol.gov/odep/topics/disability.htm. 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.
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
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 yourtickettowork.ssa.gov.
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.
Private organizations include charities and foundations. A few exist specifically to help people with kidney disease and kidney failure, such as the
Medicare recommends the following ways to save money on medications:
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.
Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at 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. Find out if clinical trials are right for you.
Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.
This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.
The NIDDK would like to thank:
Thomas Dudley, Maria Ciccanti, Eva Fung, Emerson Carvalho, and Kelly Anderson, Centers for Medicare & Medicaid Services; Leslie Pionke, M.S.W., Inova Transplant Center; Cindy Cornejo, M.S.W., DaVita Dialysis Clinic; Beth Witten, M.S.W., A.C.S.W., L.S.C.S.W., Medical Education Institute; Dori Schatell, M.S., Medical Education Institute; Amy E. Witten, B.A., Missouri Kidney Program’s Center for Chronic Kidney Disease Education