A diagnosis of end stage kidney failure can be overwhelming when considering the implications of finances and insurance coverage. It is important to be knowledgeable of Medicare, commercial and supplemental plans when discussing goals, treatment plan and expectations with the nephrologist and interdisciplinary team.
Medicare will cover 80% of treatment costs. Medicare eligibility is not based on age when it comes to dialysis patients, but rather if the person has “paid into” Medicare. If you are married you can receive benefits through your spouse if you have not “paid into” Medicare. If you are divorced, benefits can be obtained through the former spouse if you were married for ten years. The local social security office may be contacted to determine eligibility. If a person is insured through their employer, the commercial insurance will be the primary payer of dialysis costs for the first thirty months. After thirty months of coverage, Medicare becomes the primary payer and the commercial insurance becomes secondary paying 20% of the total costs.
Choice of treatment will determine when Medicare coverage begins. Hemodialysis patients will have a three month waiting period before Medicare will begin paying for treatments, whereas peritoneal dialysis patients do not have a waiting period and Medicare coverage begins the first month of treatment. If you already have Medicare prior to starting treatment, there is no waiting period.
It is important to become familiar with your insurance plan because some plans have deductibles, capitations on dialysis costs, may only cover transplant in a hospital they have contracted with and may not cover the cost of dialysis treatments when traveling out of state. Individuals 65 years and older who do not have a Medicare supplemental plan are advised to enroll in one. The supplemental plan covers 20% of costs that Medicare does not. Knowledge of insurance coverage will assist you and your interdisciplinary team in coordinating a plan of care.
Upon starting dialysis treatment, there still may be questions and concerns about insurance and finances. All dialysis clinics have social workers who are trained to help navigate the difficult transitions related to end stage kidney disease. Social workers assist patients in negotiating with Medicare/Medicaid and commercial insurance. The social worker can help enroll patients in insurance plans and obtain financial aid to cover the costs of insurance premiums and medications. Social workers work with the American Kidney Foundation and National Kidney Foundation to obtain grants for medications, co-pays, travel expenses, utility expenses and food. They are a part of an interdisciplinary team that provides support and guidance which is needed for patients to overcome challenges and meet their goals.