medicare & kidney services 2011.pdf

7/29/2019 Medicare & Kidney Services 2011.pdf

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This officialgovernment booklet explains:

The basics of Medicare

How Medicare helps pay for kidney dialysis and kidney transplants

Where to get help


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Te inormation in this booklet was correct when it was printed. Changesmay occur afer printing. Visit www.medicare.govor call 1-800-MEDICARE(1-800-633-4227) to get the most current inormation. Y users should call1-877-486-2048.

Medicare Coverage of Kidney Dialysis & Kidney Transplant Services isnt alegal document. Official Medicare Program legal guidance is contained in therelevant statutes, regulations, and rulings.
http://www.medicare.gov/http://www.medicare.gov/


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3

Contents

Introduction

Section 1: Medicare BasicsWhat is Medicare?

What Medicare covers

What Medicare costs

Part A costs

Part B costs

Paying for Part BWhos eligible?

Medicare plan choices

How to sign up for Medicare

When Medicare coverage begins

When Medicare coverage ends

How Medicare works with employer or union group health plan coverage

When the 30-month coordination period starts

When the 30-month coordination period ends

How the 30-month coordination period works if you enroll in Medicare more than onceDo I have to get Medicare if I already have an employer or union group health plan?

For more information about how employer or union group health plan coverage works with Medicare

Medicare for children with ESRD

Section 2: Kidney DialysisWhat is dialysis?

Dialysis treatment options

Dialysis services and supplies covered by Medicare

Home dialysis services and supplies NOT covered by MedicareMedicare payment system for dialysis services

Whats included in the new payment system

What YOU pay for dialysis services in a dialysis facility under the new payment system

Medicare payment for children with ESRD
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4 Table of Contents

Training for self-dialysis at home

Doctors self-dialysis training services

Home dialysis

Monthly doctor visits for home dialysis

How long will Medicare pay for home dialysis equipment?

Dialysis in a hospital

Inpatient doctors services

Outpatient doctors services

Where to get dialysis treatments

How to find a dialysis facility

Dialysis Facility Compare

Knowing how well your dialysis is working

Dialysis when you travel

Transportation to dialysis facilities

Section 3: Kidney TransplantsWhat is a kidney transplant?

Kidney transplant services covered by Medicare

Transplant drugs (called immunosuppressive drugs)

What are immunosuppressive drugs?

What if I stop taking my transplant drugs?How long will Medicare pay for transplant drugs?

What if I cant pay for the transplant drugs?

Special information about pancreas transplants

What YOU pay for kidney transplant services

Do I have to pay for my kidney donor?

Hospital services

Doctors services

Clinical laboratory services

Section 4: How Medicare Pays for BloodWhat YOU pay for blood

Having blood donated

Can I be charged for the blood that I have donated?
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5 Table of Contents

Section 5: Medicare Prescription Drug CoverageWhat it costs

Extra Help for those who need it mostHow do I apply for Extra Help?

When you can join

Section 6: Appeals & GrievancesYour Medicare rights

Appeals

Appeal rights in Original Medicare

Appeal rights in a Medicare health plan

Filing a grievance (complaint)

Section 7: Other Kinds of Health InsuranceEmployee or retiree coverage from an employer or union

Medicare Supplement Insurance (Medigap) policies

Medicaid

Veterans benefits

Other ways to get help

Section 8: Where to Get More InformationKidney organizations

End-Stage Renal Disease (ESRD) Networks

State Health Insurance Assistance Programs (SHIP)

State Survey Agency

Other Medicare products for kidney patients

Important phone numbers

Section 9: Definitions

Index
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IntroductionLearning that you have permanent kidney ailure isnt easy. Even though you may eelsad, conused, or rustrated, you can still take control o your lie. Te act that yourereading this booklet is a start.

Tis booklet explains how Medicare helps pay or kidney dialysis and kidney transplantservices in Original Medicare. In most cases, you cant join a Medicare Advantage Plan(like an HMO or PPO) i you have End-Stage Renal Disease. More ino. I youre in aMedicare Health Plan, your plan must give you at least the same coverage that OriginalMedicare gives, but your costs, rights, protections, and/or choices o where you getyour care may be different. You may also be able to get extra benefits. You can read thisbooklet to understand what Medicare covers, but youll need to read your plan materialsor call your benefits administrator or more inormation about plan rules.

alk with your health care team to learn more about permanent kidney ailure andyour treatment options. Your doctors, nurses, social workers, dieticians, and dialysistechnicians make up your health care team. Tey are there to help you decide whats bestor you based on your situation.

I you have questions about Medicare afer reading this booklet, visit www.medicare.gov,or call 1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.
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Section 1: Medicare Basics

What is Medicare?Medicare is health insurance or:

People 65 and older

People under 65 with certain disabilities

People o any age with End-Stage Renal Disease (ESRD) (permanent kidney ailurerequiring dialysis or a kidney transplant)

What Medicare covers

Medicare Part A (Hospital Insurance) helps cover:

Inpatient care in hospitals

Inpatient care in skilled nursing acilities (not custodial or long-term care)

Hospice care

Home health care

Medicare Part B (Medical Insurance) helps cover:

Services rom doctors and other health care providers

Outpatient care Home health care

Some preventive services

For more details about what Medicare covers, visit www.medicare.gov, or call1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

What Medicare costs

Part A costsMost people dont have to pay a monthly premium or Part A because they (or a spouse)paid Medicare taxes while they were working.


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8 Section 1Medicare Basics

Part B costs

Most people must pay a monthly premium or Part B. Te standard Part B premium or2012 is $99.90 per month, although it may be higher based on your income. Premiumrates can change yearly. You need Part B to get the ull benefits available underMedicare or people with ESRD, and you must pay the premium to get Part B. For moreinormation about the Part B premium, visit www.socialsecurity.gov, or call SocialSecurity at 1-800-772-1213. Y users should call 1-800-325-0778.

Paying for Part B

When you sign up or Part B, the premiumis usually taken out o your monthly SocialSecurity or Railroad Retirement payment. I you dont get one o these payments,

Medicare sends you a bill or your Part B premium every 3 months. You should get yourMedicare premium bill by the 10th o the month. I you dont get your bill by the 10th,call Social Security.

Whos eligible?

You can get Medicare no matter how old you are i your kidneys no longer work, youneed regular dialysis or have had a kidney transplant, and:

Youve worked the required amount o time under Social Security, the RailroadRetirement Board, or as a government employee.

Youre already getting or are eligible or Social Security or Railroad Retirementbenefits.

Youre the spouse or dependent child o a person who meets either o therequirements listed above.

You must also file an application, and meet any waiting periods that apply.

I you qualiy or Part A, you can also get Part B. As noted above, enrolling in Part B isyour choice, butyoull need both Part A and Part B to get the ull benefits available

under Medicare to cover certain dialysis and kidney transplant services.

I you dont qualiy or Medicare, you may be able to get help rom your state to pay oryour dialysis treatments. More Ino.
http://www.socialsecurity.gov/http://www.socialsecurity.gov/


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Call Social Security at 1-800-772-1213 or more inormation about the requiredamount o time needed under Social Security, the Railroad Retirement Board, or as agovernment employee to be eligible or Medicare based on ESRD. Y users should call1-800-325-0778. You can also visit www.socialsecurity.gov.

Medicare plan choices

Medicare generally offers different choices or how you can get your health andprescription drug coverage, although the choices may be limited i you have ESRD. Yourcosts will vary depending on your coverage and the services you use.

I you have ESRD and youre new to Medicare,youll most likely get your health care

through Original Medicare. Original Medicare is managed by the Federal government.You can go to any doctor or supplier thats enrolled in and accepts Medicare and isaccepting new Medicare patients, or to any participating hospital or other acility. Youpay a set amount or your health care (deductible) beore Medicare pays its share. Ten,Medicare pays its share, and you pay your share (coinsuranceor copayment) or coveredservices and supplies.

When you have Original Medicare, you can add prescription drug coverage by joining aMedicare Prescription Drug Plan (Part D). Private companies approved by Medicare run

these plans. Different plans cover different drugs, but most medically-necessarydrugsmust be covered. More Ino.

You usually cant join a Medicare Advantage Plan(like an HMO or PPO) i you alreadyhave ESRD, and havent had a kidney transplant. However, you may be able to join aMedicare Special Needs Plan, a type o Medicare Advantage Plan or people with certainchronic diseases, i one is available in your area or people with ESRD. Tese plans mustprovide all Part A and Part B health care and services, as well as Medicare prescriptiondrug coverage. You also may be able to join a Medicare Advantage Plan i youre already

getting your health benefits (or example, through an employer health plan) through thesame organization that offers the Medicare Advantage Plan. While youre in a MedicareAdvantage Plan, the plan will be the primary provider o your health care coverage. Youmust use your Medicare Advantage Plan ID card instead o your red, white, and blueMedicare card when you see your doctor or get other kinds o health care services.
http://www.socialsecurity.gov/http://www.socialsecurity.gov/


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I you had ESRD, but have had a kidney transplant,and you still qualiy or Medicarebenefits based on your age or a disability, you can stay in Original Medicare, or join aMedicare Advantage Plan.

I you have ESRD and are enrolled in a Medicare Advantage Plan that stops being offeredin your area, you have a one-time right to join another Medicare Advantage Plan i oneis available in your area. You dont have to use your one-time right to join a new planimmediately. I you change directly to Original Medicare afer your plan stops providingcoverage, you will still have a one-time right to join a Medicare Advantage Plan at a laterdate as long as the plan you choose is accepting new members.

For more inormation about your Medicare plan choices, look at your

Medicare & You handbook. You can visit www.medicare.gov/publicationstoview the handbook. You can also call 1-800-MEDICARE (1-800-633-4227) toget more inormation. Y users should call 1-877-486-2048.

How to sign up for Medicare

I youre eligible or Medicare because o ESRD, you can enroll in Part A and Part B byvisiting your local Social Security office or by calling Social Security at 1-800-772-1213.Y users should call 1-800-325-0778.

I you qualiy or Part A, youll also be offered Part B. As noted above, you need bothparts to get all the Medicare benefits available or ESRD, and theres a premiumorPart B. I you decide not to get Part B right away, you can only enroll January 1March 31each year. Your coverage will begin on July 1. Also, the cost o Part B will go up 10% oreach 12-month period that you could have had Part B but didnt sign up or it. I you haveemployer or union group health plan coverage, see more ino.

Note: I youre already enrolled in Medicare based on age or disability, and youre alreadypaying a higher Part B premium because you didnt enroll in Part B when you were firsteligible, the penalty will stop when you become entitled to Medicare based on ESRD. Callyour local Social Security office to make an appointment to re-enroll in Medicare basedon ESRD.
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When Medicare coverage begins

When you enroll in Medicare based on ESRD and youre on dialysis, Medicare coverage

usually starts the first day o the ourth month o your dialysis treatments. For example, iyou start getting your dialysis treatments in July, your Medicare coverage would start onOctober 1.

July: First month o dialysisAugust:Second month o dialysisSeptember:Tird month o dialysisOctober:Fourth month o dialysis. Medicare coverage begins.

I youre covered by an employer or union group health plan, or the first 30 monthsyoure covered by Medicare, your employer or union group health plan will pay first onyour health care bills, and Medicare will pay second. More Ino.

I you dont have employer group health plan coverage, there are other types oinsurance and programs that may help to pay some o your health care costs. MoreIno.

Medicare coverage can start as early as the first month o dialysis i you meet all o theollowing conditions:

You take part in a home dialysis training program offered by a Medicare-approvedtraining acility to teach you how to give yoursel dialysis treatments at home.

Your doctor expects you to finish training and be able to do your own dialysistreatments.

Medicare coverage begins the month you get a kidney transplant. Medicare coveragecan begin the month youre admitted to a Medicare-approved hospital or a kidneytransplant (or or health care services that you need beore your transplant) i yourtransplant takes place in that same month or within the ollowing 2 months.

Example:Mr. Green will be admitted to the hospital on March 11 or his kidneytransplant. His Medicare coverage will begin in March. I his transplant is delayed untilApril or May, his Medicare coverage will still begin in March.
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Important:Medicare wont cover surgery or other services needed to prepare or dialysis(such as surgery or a blood access [fistula]) beore Medicare coverage begins. However,i you complete home dialysis training, your Medicare coverage will start the month youbegin regular dialysis, and these services could be covered.

Medicare coverage can begin 2 months beore the month o your transplant i yourtransplant is delayed more than 2 months afer youre admitted to the hospital or thetransplant or or health care services you need beore your transplant.

Example: Mrs. Perkins was admitted to the hospital on May 25 or some tests sheneeded beore her kidney transplant. She was supposed to get her transplant on June15. However, her transplant was delayed until September 17. Tereore, Mrs. Perkins

Medicare coverage will start in July, 2 months beorethe month o her transplant.

Note:Tis waiting period will start even i you havent signed up or Medicare. Forexample, i you dont sign up until afer youve met all the requirements, your coveragecould begin up to 12 months beore the month you apply.

When Medicare coverage ends

I youre eligible or Medicare only because o permanent kidney ailure, your Medicare

coverage will end: 12 months afer the month you stop dialysis treatments

36 months afer the month you have a kidney transplant

Your Medicare coverage will be extended i:

You start dialysis again, or you get a kidney transplant within 12 months afer themonth you stopped getting dialysis

You start dialysis or get another kidney transplant within 36 months afer themonth you get a kidney transplant

Important: Remember, you need both Part A and Part B to get the benefitsavailable under Medicare or people with ESRD. I you dont pay your Part Bpremiumor i you choose to cancel it, your Part B coverage will end.


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How Medicare works with employer or union group health plan coverage

I youre eligible or Medicare only because o permanent kidney ailure, your eligibility

usually cant start until the ourth month o dialysis. Tis means i you have coverageunder an employer or union group health plan, that plan will be the only payer or thefirst 3 months o dialysis (unless you have other insurance).

I your employer or union plan doesnt pay all costs or dialysis, you mayhave to pay some o the costs. You may be able to get help paying thesecosts. More ino.

Once you become eligible or Medicare because o permanent kidney ailure (usuallythe ourth month o dialysis), there will still be a period o time, called a coordinationperiod, when your employer or union group health plan will continue to pay your healthcare bills. However, i your plan doesnt pay 100% o your health care bills, Medicare maypay some o the remaining costs. Tis is called coordination o benefits, under whichyour plan pays first and Medicare pays second. During this time, Medicare is calledthe secondary payer. Tis coordination period lasts or 30 months.

When the 30-month coordination period starts

Te waiting period or eligibility will start even i you havent signed up or Medicare. Te

same thing is true o the 30-month coordination period, which starts the first month youwould be eligible to get Medicare because o permanent kidney ailure (usually the ourthmonth o dialysis), even i you havent signed up or Medicare yet. For example, i youstart dialysis and are eligible or Medicare in June, the 30-month coordination period willstart September 1, the ourth month o dialysis even i you dont have Medicare.

I you take a course in sel-dialysis training or get a kidney transplant during the3-month waiting period, the 30-month coordination period will start earlier. During this30-month period, Medicare will be the secondary payer.

Important:I you have employer or union group health plan coverage, tell your healthcare provider that you have this coverage. Tis is very important to make sure that yourservices are billed correctly.
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When the 30-month coordination period ends

At the end o the 30-month coordination period, Medicare will pay first or allMedicare-covered services. Your employer or union group health plan coverage may stillpay or services not covered by Medicare. Check with your plans benefits administrator.

How the 30-month coordination period works if you enroll in Medicare more than once

Teres a separate 30-month coordination period each time you enroll in Medicare basedon permanent kidney ailure. For example, i you get a kidney transplant that continuesto work or 36 months, your Medicare coverage will end (unless you have Medicarebecause youre 65 or older or you have a certain disability). I afer 36 months you enrollin Medicare again because you start dialysis or get another transplant, your Medicarecoverage will start right away. Tere will be no 3-month waiting period beore Medicarebegins to pay. However, there will be a new 30-month coordination period i you haveemployer or union group health plan coverage.

Do I have to get Medicare if I already have an employer or union group

health plan?

No, but you should think careully about this decision. I you get a kidney transplant,youll need to take immunosuppressive drugs or the rest o your lie, so its importantto know i theyll be covered. I youre entitled to Medicare only because o ESRD (youre

not over 65 or disabled), Part B will onlycover your immunosuppressive drugs (moreino.) i you already had Part A at the time o the transplant, and the transplant surgerywas perormed at a Medicare-approved acility.

Note that Part B will only cover the immunosuppressive drugs afer youre enrolled inPart B. Tere wont be any retroactive coverage.

Note: I you dont meet the conditions or Part B coverage oimmunosuppressive drugs, you may be able to get coverage by joining aMedicare Prescription Drug Plan. More ino.


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I your group health plan coverage has a yearly deductible, copayment, or coinsurance,enrolling in Part A and Part B could help pay those costs during the coordination period.

I your group health plan coverage will pay or most or all o your health care costs (orexample, i it doesnt have a yearly deductible), you may want to delay enrolling in Part Aand Part B until the 30-month coordination period is over. I you delay enrollment,you wont have to pay the Part B premiumor coverage you dont need yet. Afer the30-month coordination period, you should enroll in Part A and Part B. Your Part Bpremium wont be higher because you delayed your enrollment. I your group health planbenefits are decreased or end during this period, you should enroll in Part A and Part Bas soon as possible.

For more information about how employer or union group health plan coverage works with Medicare

Get a copy o your plans benefits booklet.

Call your benefits administrator, and ask how the plan pays when you haveMedicare.


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Medicare for children with ESRD

Medicare covers people o all ages who have ESRD. Your child can be covered i you or

your spouse has worked the required amount o time under Social Security, the RailroadBoard, or as a government employee. Your child can also be covered i you, your spouse,or the child gets Social Security or Railroad Retirement benefits. Medicare can help coveryour childs medical costs i your child needs regular dialysis because his or her kidneysno longer work, or i he or she has had a kidney transplant.

Use the inormation in this booklet to help answer your questions, or visitwww.medicare.gov/publicationsto view the brochure Medicare or Children withEnd-Stage Renal Disease: Getting Started. You can also contact your local Social

Security office, or call 1-800-772-1213. Y users should call 1-800-325-0778.
http://www.medicare.gov/publicationshttp://www.medicare.gov/publications


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17

Section 2: Kidney Dialysis

What is dialysis?Dialysis is a treatment that cleans your blood when your kidneys dont work. It gets rido harmul waste, extra salt, and fluids that build up in your body. It also helps controlblood pressure and helps your body keep the right amount o fluids. Dialysis treatmentshelp you eel better and live longer, but they arent a cure or permanent kidney ailure.

Dialysis treatment options

Tere are 2 types o dialysis treatment options:

1. Hemodialysisuses a special filter (called a dialyzer) to clean your blood. Tefilter connects to a machine. During treatment, your blood flows through tubesinto the filter to clean out wastes and extra fluids. Ten the newly-cleaned bloodflows through another set o tubes back into your body.

2. Peritoneal dialysisuses a special solution (called dialysate) that flows through atube into your abdomen. Afer a ew hours, the dialysate has taken wastes romyour blood and can be drained rom your abdomen. Afer draining the useddialysate, your abdomen is filled with resh dialysate, and the cleaning processbegins again.

You should work with your health care team to decide the type o dialysis you need basedon your situation. Te goal is to help you stay healthy and active.


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18 Section 2Kidney Dialysis

Dialysis services and supplies covered by Medicare

Medicare covers the ollowing dialysis services and pays part o their costs:

Service or supply covered by Medicare Part A:

Inpatient dialysis treatments(i youre admitted to a hospital or special care)

Service or supply covered by Medicare Part B:

Outpatient dialysis treatments(i you get treatments in any Medicare-approveddialysis acility)

Outpatient doctors services(more ino) Sel-dialysis training(includes instruction or you and the person helping you with

your home dialysis treatments) Home dialysis equipment and supplies(like the machine, water treatment system,

basic recliner, alcohol, wipes, sterile drapes, rubber gloves, and scissors) (more ino)

Certain home support services(may include visits by trained hospital or dialysisacility workers to check on your home dialysis, to help in emergencies whenneeded, and to check your dialysis equipment and water supply) (more ino)

Most drugs or home dialysis(more ino)

Other services and supplies that are a part o dialysis(like laboratory tests)

o find out what you pay or these services, see more ino.
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Home dialysis services and supplies NOT covered by Medicare

Medicare doesntcover the ollowing services or supplies:

Paid dialysis aides to help you with home dialysis

Any lost pay to you or the person who may be helping you during sel-dialysistraining

A place to stay during your treatment

Blood or packed red blood cells or home sel-dialysis unless part o a doctorsservice

Tere are some types o insurance that may pay some o the health care costs that

Medicare doesnt pay. More ino.For more inormation on Medicare prescription drugcoverage, see more ino.


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Medicare payment system for dialysis services

A new payment system called the ESRD Prospective Payment System (PPS) went into

effect on January 1, 2011. Tis payment system bundles or combines all o the Part BESRD dialysis services and items that were previously grouped under the compositerate and those ESRD dialysis items or services that were previously billed separately.Te composite rate is the ormer method that Medicare used to pay dialysis acilities ordialysis-related services.

Whats included in the new payment system

Te new payment system includes the ollowing Part B covered services and items:

Dialysis-related services, equipment, and supplies that were in the prior compositerate

Injectable drugs and their oral orms and biologicals, including erythropoiesisstimulating agents used or ESRD dialysis treatment*

Laboratory tests and other items and services provided or ESRD dialysis treatment

Home dialysis training by a Medicare-certified home dialysis training acility (i youchoose to get dialysis at home)

*Medications that are only available in oral orm will continue to be covered under

Medicare prescription drug coverage (Part D). alk with your doctor or health care teamabout the use o any drugs, including over-the-counter products.


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What YOU pay for dialysis services in a dialysis facility under the new payment

system

I you have Original Medicare, youll continue to pay 20% o the Medicare-approvedamountor all covered dialysis related services. Medicare will pay the remaining 80%.

Te amount (20%) or which youre responsible may vary under the new payment system.I youre in a Medicare Advantage Plan(like an HMO or PPO) or have a MedicareSupplement Insurance (Medigap) policy that covers all or part o your 20% coinsurance,then your costs may be different. Read your plan materials or call your benefitsadministrator to get your cost inormation. You must also continue to pay your monthlyPart B and Part D (i applicable) premiums.

Note:Your 20% copayment covers all o the services and items listed here. Since theseservices and items are included in the new bundled payment system, you cantbe billedseparately or them. You also dont need to get the drugs that are included in the bundlerom your Medicare drug plan (i you have one).

Medicare payment for children with ESRD

I you have a child under 18 who has Medicare coverage because o ESRD, the payment

rules are the same as described above. However, the rates paid to the dialysis acilitiesare adjusted based on the childs age and the type o dialysis they get. Tese adjustmentsallow or the special care needs o children.
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Training for self-dialysis at home

raining or sel-dialysis at home is covered under Part B on an outpatient basis, but

only in a acility certified or dialysis training. You may qualiy or training i you thinkyou would benefit rom sel-dialysis training or at-home treatments, and your doctorapproves. raining sessions will occur at the same time you get dialysis treatment and aresubject to a maximum number o sessions.

Doctors self-dialysis training services

In Original Medicare, Medicare pays your kidney doctor a flat ee to supervisesel-dialysis training. Afer you pay the Part B yearly deductible($140 in 2012), Medicarepays 80% o the flat ee and you pay the remaining 20%.

Example: (What you pay may be different than whats shown.)Lets say the flat ee or the doctor whos supervising the sel-dialysis training is $500.Afer you pay the Part B yearly deductible, here are the costs:

Medicare pays 80% o the $500 (or $400).

You pay the remaining 20% coinsurance(or $100).

Home dialysis

Your dialysis acility will be responsible or providing all o your home dialysis

related items and services including equipment and supplies (either directly or underarrangement). Under the new payment system, home dialysis equipment and suppliesprovided directly rom dialysis suppliers (ormerly reerred to as Method II) are nolonger available. However, dialysis suppliers may provide equipment and supplies underarrangement with your dialysis acility. Medicare pays or home dialysis at the same rateas dialysis you get in a acility.

Monthly doctor visits for home dialysis

Medicare pays doctors (and certain non-doctors, such as physician assistants and nursepractitioners), on a monthly basis, to help people with Medicare who perorm sel-dialysisat home manage their care. Tis benefit includes a ace-to-ace visit between you and yourdoctor once a month. Te ace-to-ace visit allows you and your doctor to discuss yourcare and the effectiveness o your dialysis, to check or complications, and to give you achance to ask questions about your home dialysis treatment.


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How long will Medicare pay for home dialysis equipment?

Part B will pay or home dialysis equipment as long as you need dialysis at home. I youno longer need home dialysis (or example, i you had a kidney transplant), Part B wouldstop paying.

Dialysis in a hospital

I youre admitted to a hospital and get dialysis, your treatments will be covered by Part Aas part o the costs o your covered inpatient hospital stay.

Inpatient doctors services

In Original Medicare, your kidney doctor bills separately or the Medicare-covered ESRD

services you get as an inpatient. In this case, your kidney doctors monthly payment willbe based on the number o days you stay in the hospital.

Outpatient doctors services

In Original Medicare, Medicare pays most kidney doctors a monthly amount. Aferyou pay the Part B yearly deductible($140 in 2012), Medicare pays 80% o the monthlyamount. You pay the remaining 20% coinsurance.

In some cases, your doctor may be paid per day i you get services or less than 1 month.

Example:(What you pay may be different than whats shown.)Lets say the monthly amount that Medicare pays your doctor or each dialysis patient is$125. Afer you pay the Part B yearly deductible, here are the costs:

Medicare pays 80% o the $125 (or $100).

You pay the remaining 20% coinsurance (or $25).


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Where to get dialysis treatments

Dialysis can be done at home or in a Medicare-certified dialysis acility. For Medicare to

pay or your treatments, the acility must be approved by Medicare to provide dialysis(even i the acility already provides other Medicare-covered health care services).

At the dialysis acility, a nurse or trained technician may give you the treatment. Athome, you can treat yoursel or you can ask a amily member or riend or help. I youdecide to do home dialysis, you and your helper(i you have one) will get training.

I you have a problem with the care youre getting rom your dialysis acility, you have theright to file a grievance(complaint) to resolve your problem. See here, Filing a grievance(complaint), or more inormation.

How to find a dialysis facility

In most cases, the acility your kidney doctor works with is where you will get dialysistreatments. However, you have the right to choose to get your treatments rom anotheracility at any time, but this could mean changing doctors.

You can also call your local ESRD Network (more ino) to find a dialysis acility thats

close to you, or you can use Dialysis Facility Compare by visiting www.medicare.gov/dialysis.

Dialysis Facility Compare

Dialysis Facility Compare has important inormation about Medicare-certified dialysisacilities in your area and around the country. Visit www.medicare.gov/dialysis . You canfind inormation such as addresses and phone numbers, how ar certain acilities arerom you, and what kind o dialysis services the acilities offer. You can also compareacilities by the services they offer and by certain quality o care inormation. Helpul

Web sites, publications, and phone numbers are also available. You can discuss theinormation on this Web site with your health care team.

I you dont have a computer, your local library or senior center may be able to help youlook at this inormation. You can also call 1-800-MEDICARE (1-800-633-4227), orcontact your local State Health Insurance Assistance Program (more ino) to get helpwith comparing dialysis acilities. Y users should call 1-877-486-2048.
http://www.medicare.gov/dialysishttp://www.medicare.gov/dialysishttp://www.medicare.gov/dialysishttp://www.medicare.gov/dialysishttp://www.medicare.gov/dialysishttp://www.medicare.gov/dialysis


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Knowing how well your dialysis is working

With the right type and amount o dialysis, youll probably eel better and less tired, have

a better appetite and less nausea, have ewer hospital stays, and live longer.

You can tell how well the dialysis is working with blood tests that keep track o your URRor Kt/V (pronounced kay tee over vee) number. Tese numbers tell your doctor ornurse how well dialysis is removing wastes rom your body. Your doctor or nurse usuallykeeps track o one or both o these numbers, depending on which test your dialysisacility uses.

A URR o 65% and a Kt/V o 1.2 are the minimumnumbers or adequate dialysis. Yourhealth care provider or dialysis center may set a higher dialysis goal or your health andto make you eel better. alk to your health care provider about your number.

Even i you eel fine, you should still check how well your dialysis is working.

For a short period o time, you may eel okay without adequate dialysis. However, overtime, not getting adequate dialysis can make you eel weak and tired. It can lead to ahigher risk o inection and prolonged bleeding. It can shorten your lie.

Here are some steps you can take to get adequate dialysis:

Go to all o your scheduled treatments and arrive on time. Stay or the ull treatment time.

Follow your diet and fluid restrictions.

Follow the advice o your dialysis staff on taking care o yoursel.

Check your URR or Kt/V adequacy number every month.

alk to your doctor about which hemodialysis vascular access* isbest or you.

Learn how to take care o your vascular access.

o learn more about how well your dialysis is working, talk with your doctor or otherhealth team members at your dialysis acility.

* Your vascular access is the entrance your doctor makes into your blood vessels. Duringdialysis, your blood is removed and returned through your vascular access.


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Dialysis when you travel

You can still travel within the United States i you need dialysis. Tere are over 5,000

dialysis acilities around the country. Your acility can help you plan your treatmentalong the route o your trip beore you travel. Your dialysis acility will help you bychecking to see i the acilities on your route:

Are approved by Medicare to give dialysis

Have the space and time to give care when you need it

Have enough inormation about you to give you the right treatment

In general, Medicare will only pay or hospital or medical care that you get in the UnitedStates.

Note: I you get your dialysis services rom a Medicare Advantage Plan, your plan maybe able to help you arrange to get dialysis while you travel. Contact your plan or moreinormation.


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Transportation to dialysis facilities

Medicare covers ambulance services to and rom your home to the nearest dialysis

acility or treatment o ESRD onlyi other orms o transportation would be harmul toyour health.

For non-emergency, scheduled, repetitive ambulance services, the ambulance suppliermust get a written order rom your doctor beore you get the ambulance service. Tedoctors written order must certiy that ambulance transportation is medically necessaryand must be dated no earlier than 60 days beore you get the ambulance service.

I youre in a Medicare Advantage Plan, the plan may cover some non-ambulance

transportation to dialysis centers and doctors. Read your plan materials, or call the planor more inormation.

For more inormation about ambulance coverage, visit www.medicare.gov/publicationstoread or print the booklet Medicare Coverage o Ambulance Services. You can also call1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

Visit www.medicare.gov/dialysis to get inormation about Medicare-certified dialysisacilities in your area.
http://www.medicare.gov/publicationshttp://www.medicare.gov/dialysishttp://www.medicare.gov/dialysishttp://www.medicare.gov/publications


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28

Section 3: Kidney Transplants

What is a kidney transplant?A kidney transplant is a type o surgery thats done to put a healthy kidney rom anotherperson into your body. Tis new kidney does the work that your own kidneys can nolonger do. You may get a kidney rom someone who has recently died, or rom someonewho is still living, like a amily member. Te blood and tissue o the person who givesyou the kidney must be tested to see how well they match yours so that your body wontreject the new kidney.

o be covered by Medicare, your kidney transplant must be done in a hospital thats

approved by Medicare to do kidney transplants.

I you have a problem with the care that youre getting or your transplant,you have the right to file a grievance(complaint). See here, Filing a grievance(complaint), or more inormation.


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29 Section 3Kidney Transplants

Kidney transplant services covered by Medicare

Medicare covers the ollowing transplant services and pays part o their costs:

Service or supply covered by Medicare Part A:

Inpatient services in an approved hospital

Kidney registry ee

Laboratory and other tests needed to evaluate your medical condition*

Laboratory and other tests needed to evaluate the medical condition o potentialkidney donors*

Te costs o finding the proper kidney or your transplant surgery (i theres nokidney donor)

Te ull cost o care or your kidney donor(including care beore surgery, theactual surgery, and care afer surgery)

Any additional inpatient hospital care or your donor in case o problems due tothe surgery

Service or supply covered by Medicare Part B:

Doctors services or kidney transplant surgery (including care beore surgery, theactual surgery, and care afer surgery)

Doctors services or your kidney donor during their hospital stay Immunosuppressive drugs (or a limited time afer you leave the hospital ollowing

a transplant).More ino. Seehereor inormation about Medicare PrescriptionDrug Plans.

Service or supply covered by Medicare Part A and Part B:

Blood (whole or units o packed red blood cells, blood components, and the cost oprocessing and giving you blood). More ino.

o find out what you pay or these services, see here.

* Tese services are covered whether they are done by the Medicare-approved hospitalwhere you will get your transplant, or by another hospital that participates in Medicare.

Note: Buying or selling human organs is against the law. Tereore, Medicare doesnt payor the kidneys used or transplant.
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Transplant drugs (called immunosuppressive drugs)

What are immunosuppressive drugs?

Immunosuppressive drugs are transplant drugs used to reduce the risk o your bodyrejecting your new kidney afer your transplant. Youll need to take these drugs or therest o your lie.

Important: You must meet the conditions listed hereor Medicare to cover yourimmunosuppressive drugs.

What if I stop taking my transplant drugs?

I you stop taking your transplant drugs, your body may reject your new kidney, and the

kidney could stop working. I that happens, you may have to start dialysis again. alk toyour doctor beore you stop taking your transplant drugs.

How long will Medicare pay for transplant drugs?

I youre entitled to Medicare only because o permanent kidney ailure, your Medicarecoverage will end 36 months afer the month o the transplant.

Medicare wont pay or any services or items, including immunosuppressive drugs, orpatients who arent entitled to Medicare.

Medicare will continue to pay or your immunosuppressive drugs with no time limitiyou:

Were already entitled to Medicare because o age or disability beore you got ESRD

Became entitled to Medicare because o age or disability afer getting a transplantthat was paid or by Medicare, or paid or by private insurance that paid primary toyour Part A coverage, in a Medicare-certified acility

I youre entitled to Medicare only because o permanent kidney ailure, your

Medicare coverage will end when your 36-month period is over.
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What if I cant pay for the transplant drugs?

ransplant drugs can be very costly. I youre entitled to Medicare only because opermanent kidney ailure, your immunosuppressive drugs are only covered or 36months afer the month o your transplant. I youre worried about paying or them aferyour Medicare coverage ends, talk to your doctor, nurse, or social worker. Tere may beother ways to help you pay or these drugs. See hereto learn more about other healthinsurance options.

Special information about pancreas transplants

I you have ESRD and need a pancreas transplant, Medicare covers the transplant i oneo the ollowing applies:

Its done at the same time you get a kidney transplant. Its done afer a kidney transplant.

Note:In some rare cases Medicare may cover a pancreas transplant even i you dontneed a kidney transplant.

I youre entitled to Medicare only because o permanent kidney ailure, and youhave the pancreas transplant afer the kidney transplant, Medicare will only pay oryour immunosuppressive drug therapy or 36 months afer the month o the kidney

transplant. Tis is because your Medicare coverage will end 36 months afer a successulkidney transplant i you only have Medicare due to permanent kidney ailure.

I you were already entitled to Medicare because o age or disability beore you gotESRD, or i you became eligible or Medicare because o age or disability afer getting atransplant, Medicare will continue to pay or your immunosuppressive drugs with notime limit.

What YOU pay for kidney transplant services

Te amounts listed in this section are or transplant services covered in OriginalMedicare. I youre in a Medicare Advantage Plan, your costs may be different. Read yourplan materials, or call your plan to get inormation about your costs.

Do I have to pay for my kidney donor?

No. Medicare will pay the ull cost o care or your kidney donor. You dont have to pay adeductible, coinsurance, or other costs or your donors hospital stay.


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Hospital services

I you have Original Medicare, in 2012 you pay:

$1,156 deductible per benefit period

$0 or the first 60 days o each benefit period

$289 per day or days 6190 each benefit period

$578 per lietime reserve day* afer day 90 each benefit period (up to 60 days overyour lietime)

All costs or each day afer the lietime reserve days

For Medicare-approved care in a skilled nursing acility, you pay:

$0 or the first 20 days each benefit period

Up to $144.50 per day or days 21100 each benefit period All costs or each day afer day 100 in the benefit period

o find out what you pay or other Part A and Part B services, visit www.medicare.gov, orcall 1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

*In Original Medicare, lietime reserve days are additional days that Medicare will payor when youre in a hospital or more than 90 days. You have a total o 60 reserve daysthat can be used during your lietime. For each lietime reserve day, Medicare pays all

covered costs except or a daily coinsurance.

Doctors services

In Original Medicare, you must pay the Part B yearly deductible($140 in 2012). Afer youpay the deductible, Medicare pays 80% o the Medicare-approved amount. You must paythe remaining 20% coinsurance.

Important: Teres a limit on the amount your doctor can charge you, even i yourdoctor doesnt accept assignment. I your doctor doesnt accept assignment, you only have

to pay the part o the bill that is up to 15% over the Medicare-approved amount.

Clinical laboratory services

You pay nothing or Medicare-approved laboratory tests.


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33

Section 4: How Medicare Pays for BloodIn most cases, Medicare Part A and Part B help pay or:

Whole blood units or packed red blood cells

Blood components

Te cost o processing and giving you blood

What YOU pay for blood

Under both Part A and Part B, in most cases, the hospital gets blood rom a blood bankat no charge, and you wont have to pay or it or replace it. I the hospital has to buy blood

or you, you must either pay the hospital or the first 3 units o whole blood or equivalentunits o packed red blood cells that you get in a calendar year while youre staying in ahospital or skilled nursing acility or replace the blood. See Having Blood Donatedhere.

You pay a copaymentor additional units o blood you get as an outpatient (afer the first3), and the Part B deductibleapplies.

Note: Once you have paid or or replaced the required units o blood, you dont have todo so again under either Part A or Part B or the remainder o the calendar year.


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34 Section 4How Medicare Pays for Blood

Having blood donated

You can replace the blood by donating it yoursel, or getting another person or

organization to donate the blood or you. Te blood thats donated doesnt have to matchyour blood type. I you decide to donate the blood yoursel, check with your doctor first.

Can I be charged for the blood that I have donated?

No. A hospital or skilled nursing acility cant charge you or any o the first 3 pints oblood you have already donated or will have donated.

Medicare doesnt pay or blood or home sel-dialysis unless its part o adoctors service or is needed to prime the dialysis equipment.


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35

Section 5: Medicare Prescription Drug CoverageMedicare Part B covers immunosuppressive drugs afer a covered transplant and mosto the drugs you get or dialysis. More ino.However, it doesnt cover prescription drugsor other health conditions you may have, like high blood pressure or diabetes. Medicareoffers prescription drug coverage to help you with the costs o your drugs not covered byPart B.

Medicare prescription drug coverage wont cover drugs you can get underPart Blike immunosuppressive drug therapy under the conditions discussedhere. However, i you dont meet the conditions listed here, you may be able toget coverage o your immunosuppressive drug therapy by joining a MedicarePrescription Drug Plan.

Medicare prescription drug coverage (Part D) is offered by private companies approvedby Medicare. Tere are 2 types o Medicare plans that provide Medicare prescriptiondrug coverage:

Medicare Prescription Drug Plans that add coverage to Original Medicareor certaintypes o Medicare health plans.

Medicare prescription drug coverage provided as part o Medicare Advantage Plans(like an HMO or PPO). Most people with ESRD can onlyget prescription drugcoverage through a Medicare Advantage Plan i they already belong to a plan, or ithey switch to a different plan offered by the same company.

What it costs

Most Medicare drug plans charge a monthly premiumthat varies by plan. Your premiummay be higher based on your income. You pay the Part D premium in addition to thePart B premium. Some plans have no premium at all. Your costs will vary depending onwhich drugs you use and which drug plan you choose. Also, i you have limited income

and resources, you may be able to get Extra Help paying or your Part D prescriptiondrug costs. More ino.Look at your Medicare & You handbook to get detailedinormation about prescription drug coverage costs.
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36 Section 5Medicare Prescription Drug Coverage

Extra Help for those who need it most

Medicare provides Extra Help to pay prescription drug costs or people who meet specific

income and resource limits. Resources include your savings and stocks, but not yourhome or car. I you qualiy, youll get help paying or your Medicare drug plans monthlypremium, yearly deductible, and prescription copaymentsor coinsurance.

o qualiy or Extra Help, your yearly income must be below $16,755 ($22,695 or amarried couple living together), and your resources may be up to $13,070 ($26,120 or amarried couple living together). Tese amounts may change in 2013.

I you live in Alaska or Hawaii, or pay more than hal o the living expenses o dependentamily members, your income limits are higher. Resources dont include your home,car, household items, burial plot, up to $1,500 or burial expenses (per person) or lieinsurance policies.

Note: Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, andAmerican Samoa provide their residents help with Medicare drug costs. Tis help isntthe same as the Extra Help described here. Call your local Medical Assistance (Medicaid)office to learn more.


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How do I apply for Extra Help?

Some people with Medicare automatically qualiy or Extra Help and will get a letterrom Medicare.

I you didnt automatically qualiy, call Social Security at 1-800-772-1213, visit www.socialsecurity.gov, or apply at your State Medical Assistance (Medicaid) office. Yusers should call 1-800-325-0778. Afer you apply, you will get a letter in the mail lettingyou know i you qualiy and what to do next. Even i you dont qualiy, you should stillconsider joining a Medicare Prescription Drug Plan.

I you apply and qualiy or Extra Help, you can either join a plan on your own or letMedicare enroll you in a plan. Medicare will send you a letter letting you know what

plan it will enroll you in and when your coverage begins. Check to see i the plan youreenrolled in covers the drugs you use and i you can go to the pharmacies you want. I not,you can change plans at any time.

When you can join

I you become entitled to Medicare based on ESRD, your first chance to join a Medicaredrug plan will be during the 7-month period that begins 3 months beore the monthyoure entitled to Medicare and ends 3 months afer the first month youre entitled to

Medicare.

Your prescription drug coverage will start the same time your Medicare coverage beginsor the first month afer you make your request, whichever is later. More ino.
http://www.socialsecurity.gov/http://www.socialsecurity.gov/http://-/?-http://-/?-http://www.socialsecurity.gov/http://www.socialsecurity.gov/


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I you dont join when youre first eligible, you can join between October 15December7 each year. Your coverage will begin on January 1 o the ollowing year. I you join aferyour initial enrollment period is over and there was a period o 63 continuous days ormore during which you didnt have creditable prescription drug coverage (coverage thatis expected to pay, on average, at least as much as Medicares standard prescription drugcoverage),you may have to pay a late enrollment penalty. Tis amount increases thelonger you go without creditable coverage. You will have to pay this penalty as long as youhave Medicare prescription drug coverage. However, i you get Extra Help, you dont haveto pay a late enrollment penalty.

For more inormation about Medicare prescription drug coverage, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

You can also contact your local State Health Insurance Assistance Program. More ino.
http://www.medicare.gov/http://www.medicare.gov/http://www.medicare.gov/http://www.medicare.gov/


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39

Section 6: Appeals & Grievances

Your Medicare rightsI you have Medicare, you have certain guaranteed rights to help protect you. One othese is the right to a process or appealing decisions about health care payment orservices. Whether you have Original Medicareor a Medicare Advantage Plan(like anHMO or PPO), you have the right to appeal, and to file grievances.

Appeals

An appeal is the action you can take i you disagree with a coverage or payment decision

made by Medicare, your Medicare Health Plan, or your Medicare Prescription DrugPlan. You can appeal i Medicare or your plan denies:

Your request or a health care service, supply, or drug that you think you should beable to get

Your request or payment or health care services or supplies or a prescription drugyou already got

Your request to change the amount you must pay or a prescription drug

You can also appeal i Medicare or your plan stops providing or paying or all or part o

an item or service you think you still need.

Appeal rights in Original Medicare

I you have Original Medicare, you can file an appeal i you arent satisfied with acoverage or payment decision. I you file an appeal, ask your doctor or provider or anyinormation related to the bill that might help your case. Your appeal rights are on theback o the Medicare Summary Notice (MSN) that is mailed to you rom a company thathandles bills or Medicare. Te notice will also tell you why Medicare didnt pay your bill

and how you can appeal. Please review your Medicare notices careully and ollow theinstructions beore filing an appeal.


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40 Section 6Appeals & Grievances

Appeal rights in a Medicare health plan

I youre in a Medicare health plan, or a Medicare Prescription Drug Plan, you

can file an appeal or any o the reasons listed here. For more inormation on yourappeal rights, see your plans membership materials, contact your plan, or visitwww.medicare.gov/publicationsto view the booklet, Medicare Appeals. You may alsocall 1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

Filing a grievance (complaint)

A grievanceis different rom an appeal. A grievance is or problems you have with theway you get services. I you have a problem with your ESRD dialysis acility:

alk with your doctor, nurse, or acility administrator first to see i they can helpyou solve your problem. Most problems can be handled at your acility.

File a grievance (a written complaint) with your acility i talking to your health careteam doesnt solve the problem.

Every acility has a grievance policy or accepting and trying to work out your problemsor concerns. I you dont know your acilitys grievance policy, ask or a copy o it.

I you filed a grievance with your acility and you still eel that your problem has notbeen solved, you have the right to file a grievance with the ESRD Network in your area.More ino.Call the ESRD Network to find out how to file a grievance. You can also callyour State Survey Agency to complain about your care. Your calls and name will be keptprivate.Visit www.medicare.gov/contactsto get the phone number to the State SurveyAgency. You can also call 1-800-MEDICARE.
http://www.medicare.gov/publicationshttp://www.medicare.gov/contactshttp://www.medicare.gov/contactshttp://www.medicare.gov/publications


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41

Section 7: Other Kinds of Health InsuranceTere are other kinds o health insurance coverage that may help pay or the services youneed or the treatment o permanent kidney ailure. Tey include:

Employee or retiree coverage rom an employer or union


Medicaid

Veteran Administration benefits

Employee or retiree coverage from an employer or union

I you have group health plan coverage based on your or your spouses past or currentemployment, call your benefits administrator to find out what coverage they mightprovide or your permanent kidney ailure. I youre eligible or coverage under the grouphealth plan, but havent yet signed up or it, call the benefits administrator to find out iyou can still enroll.

Generally, employer plans have better rates than you can get i you buy a policy directlyrom an insurance company. Also, employers may pay part o the cost o the coverage.

See hereor an explanation o when your employer will pay first, and when Medicare willpay first with your employer providing supplemental coverage.

I you lose your employer or union coverage, you may be able to continue your coveragetemporarily through COBRA. Tis Federal law allows you to temporarily keep youremployer or union health coverage afer your employment ends or afer you lose coverageas a dependent o a covered employee. alk to your benefits administrator or moreinormation.
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42 Section 7Other Kinds of Health Insurance


A Medigap policy is health insurance sold by private insurance companies to help fill the

gaps in Original Medicarecoverage, like deductiblesand coinsurance. Medigap policieshelp pay some o the health care costs that Original Medicare doesnt cover. Medigapinsurance must ollow Federal and state laws that protect you. All Medigap policies areclearly marked Medicare Supplement Insurance.

Not all insurance companies will sell Medigap policies to people with Medicare under 65.I a company does sell Medigap policies voluntarily, or because state law requires it, theseMedigap policies will probably cost you more than i you were 65 or older. Medigap rules

vary rom state to state. Call your State Health Insurance Assistance Program (more

ino) or inormation about buying a Medigap policy i youre disabled or have ESRD.When you turn 65, you will be guaranteed an opportunity to buy a Medigap policy.

For detailed inormation about Medigap policies:

Visit www.medicare.gov/publicationsto read or print a copy o Choosing aMedigap Policy: A Guide to Health Insurance or People with Medicare.

Visit www.medicare.gov/medigapto get inormation about Medigap policies in yourstate. When you use this Web site, youll get a personalized summary page withgeneral inormation to help you compare plans. You can get detailed inormation

about all the plans available in your area, or just the ones youre most interested in.Tis Web site has the ollowing inormation:

Which Medigap policies are sold in your state

Comparing Medigap policies

What each policy covers

Your out-o-pocket costs

I you dont have a computer, your local library or senior center may be able to help youlook at this inormation.
http://www.medicare.gov/publicationshttp://www.medicare.gov/medigaphttp://www.medicare.gov/medigaphttp://www.medicare.gov/publications


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Medicaid

Tis is a joint Federal and state program that helps pay medical costs or some people

with limited income and resources. Medicaid programs vary rom state to state. Mosthealth care costs are covered i you qualiy or both Medicare and Medicaid and seeproviders who accept both.

States also have Medicare Savings Programs that pay some or all o Medicares premiumsand may also pay Medicare deductiblesand coinsuranceor certain people who haveMedicare and a limited income. o qualiy or these programs, generally you must have:

Medicare Part A.

A monthly income o less than $1,277 or an individual or $1,723 or a couple in

2012. Tese income limits are slightly higher in Hawaii and Alaska. Income limitscan change each year.

Savings o $6,940 or less or an individual, or $10,410 or less or a couple. Savingsinclude money in a checking or savings account, stocks, and bonds.

o get more inormation on these programs, visit www.medicare.gov. You can also call1-800-MEDICARE (1-800-633-4227), and ask or inormation on savings or peoplewith Medicare. Y users should call 1-877-486-2048.


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Veterans benefits

I youre a veteran, the U.S. Department o Veterans Affairs can help pay or ESRD

treatment. For more inormation, call the U.S. Department o Veterans Affairs at1-800-827-1000. Y users should call 1-800-829-4833. I you or your spouse is activeduty or retired rom the military, call the Department o Deense at 1-800-538-9552 ormore inormation. Y users should call 1-866-363-2883.

Other ways to get help

In most states there are agencies and state kidney programs that help with some o thehealth care costs that Medicare doesnt pay. Call your State Health Insurance AssistanceProgram i you have questions about health insurance. More ino.


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45

Section 8: Where to Get More Informationalk with your health care team to learn more about kidney dialysis, transplants, andyour situation.

Kidney organizations

Tere are special organizations that can give you more inormation about kidney dialysisand kidney transplants. Some o these organizations have members who are on dialysisor have had kidney transplants and who can give you support.

American Association o Kidney Patients

3505 East Frontage Road, Suite 315ampa, Florida 336071-800-749-2257www.aakp.org

American Kidney Fund6110 Executive Boulevard, Suite 1010Rockville, Maryland 208521-800-638-8299

www.kidneyund.org

Dialysis Patient Citizens900 7th Street, NW, Suite 670Washington, DC 200011-866-877-4242www.dialysispatients.org

National Kidney Foundation, Inc.30 East 33rd StreetNew York, New York 100161-800-622-9010www.kidney.org

National Kidney and Urologic Diseases Inormation Clearinghouse3 Inormation WayBethesda, Maryland 208921-800-891-5390www.kidney.niddk.nih.gov
http://www.aakp.org/http://www.kidneyfund.org/http://www.dialysispatients.org/http://www.kidney.org/http://www.kidney.niddk.nih.gov/http://www.kidney.niddk.nih.gov/http://www.kidney.org/http://www.dialysispatients.org/http://www.kidneyfund.org/http://www.aakp.org/


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46 Section 8Where to Get More Information

End-Stage Renal Disease (ESRD) Networks

You can call your local ESRD Network Organization (more ino) to get inormation

about the ollowing: Dialysis or kidney transplants

How to get help rom other kidney-related agencies

Problems with your acility that arent solved afer talking toacility staff

Location o dialysis acilities and transplant centers

Your ESRD Network makes sure that youre getting the best possible care and keeps youracility aware o important issues about kidney dialysis and transplants.

State Health Insurance Assistance Programs (SHIP)

Call your State Health Insurance Assistance Program (more ino) if you have questionsabout:

Medigap policies

Medicare health plan choices

Filing an appeal

Other general health insurance questions

State Survey Agency

Te State Survey Agency inspects dialysis acilities and makes sure that Medicarestandards are met. Your State Survey Agency can also help you i you have a complaintabout your care. Visitwww.medicare.gov/contactsto get the phone number o your State Survey Agency.You can also call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048. Your calls and name will be kept private.
http://www.medicare.gov/contactshttp://www.medicare.gov/contacts


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Other Medicare products for kidney patients

o read or print a copy o these booklets, visit

www.medicare.gov/publications. You can also call 1-800-MEDICARE (1-800-633-4227)to find out i a copy can be mailed to you. Y users should call 1-877-486-2048.

3. Dialysis Facility CompareTis brochure gives you inormation about the Dialysis Facility Compare tool atwww.medicare.gov/dialysis .

4. Medicares Coverage o Dialysis and Kidney ransplant Benefits: GettingStartedTis brochure explains basic Medicare benefits or people with kidney disease.

5. Medicare or Children with End-Stage Renal DiseaseTis brochure gives inormation about Medicare coverage or children withpermanent kidney ailure.

Important phone numbers

ESRD Networks and State Health Insurance Assistance Program phone numbers areound here. At the time o printing, these phone numbers were correct. Phone numberssometimes change. o get the most updated phone numbers, visit

www.medicare.gov/contacts. You can also call 1-800-MEDICARE.
http://www.medicare.gov/publicationshttp://www.medicare.gov/dialysishttp://www.medicare.gov/contactshttp://www.medicare.gov/contactshttp://www.medicare.gov/dialysishttp://www.medicare.gov/publications


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State Health Insurance Assistance Program by State

Alabama . . . . . . . . . . . 1-800-243-5463

Alaska . . . . . . . . . . . . . 1-800-478-6065

American Samoa. . . . Not available

Arizona. . . . . . . . . . . . 1-800-432-4040

Arkansas. . . . . . . . . . . 1-800-224-6330

Caliornia . . . . . . . . . . 1-800-434-0222

Colorado . . . . . . . . . . . 1-888-696-7213

Connecticut . . . . . . . . 1-800-994-9422

Delaware . . . . . . . . . . . 1-800-336-9500

Florida. . . . . . . . . . . . . 1-800-963-5337

Georgia . . . . . . . . . . . . 1-866-552-4464

Guam . . . . . . . . . . . . . 1-671-735-7388

Hawaii . . . . . . . . . . . . . 1-888-875-9229

Idaho. . . . . . . . . . . . . . 1-800-247-4422

Illinois . . . . . . . . . . . . . 1-800-548-9034

Indiana . . . . . . . . . . . . 1-800-452-4800

Iowa. . . . . . . . . . . . . . . 1-800-351-4664

Kansas . . . . . . . . . . . . . 1-800-860-5260

Kentucky. . . . . . . . . . . 1-877-293-7447

Louisiana . . . . . . . . . . 1-800-259-5300

Maine . . . . . . . . . . . . . 1-877-353-3771

Maryland . . . . . . . . . . 1-800-243-3425

Massachusetts . . . . . . 1-800-243-4636

Michigan. . . . . . . . . . . 1-800-803-7174

Minnesota. . . . . . . . . . 1-800-333-2433

Mississippi . . . . . . . . . 1-800-948-3090

Missouri . . . . . . . . . . . 1-800-390-3330

Montana . . . . . . . . . . . 1-800-551-3191

Nebraska. . . . . . . . . . . 1-800-234-7119

Nevada . . . . . . . . . . . . 1-800-307-4444

New Hampshire . . . . 1-866-634-9412

New Jersey . . . . . . . . . 1-800-792-8820

New Mexico . . . . . . . 1-800-432-2080

New York . . . . . . . . . . 1-800-701-0501

North Carolina . . . . . 1-800-443-9354

North Dakota. . . . . . . 1-888-575-6611

Ohio . . . . . . . . . . . . . . 1-800-686-1578

Oklahoma . . . . . . . . . 1-800-763-2828

Oregon . . . . . . . . . . . . 1-800-722-4134

Pennsylvania . . . . . . . 1-800-783-7067

Puerto Rico . . . . . . . . 1-877-725-4300

Rhode Island . . . . . . . 1-401-462-0510

South Carolina . . . . . 1-800-868-9095

South Dakota . . . . . . 1-800-536-8197

ennessee . . . . . . . . . . 1-877-801-0044

exas . . . . . . . . . . . . . . 1-800-252-9240

Utah. . . . . . . . . . . . . . . 1-800-541-7735

Vermont . . . . . . . . . . . 1-800-642-5119

Virgin Islands . . . . . . 1-340-772-7368

Virginia . . . . . . . . . . . 1-800-552-3402

Washington . . . . . . . . 1-800-562-6900

Washington D.C. . . . . 1-202-739-0668

West Virginia . . . . . . 1-877-987-4463

Wisconsin. . . . . . . . . . 1-800-242-1060

Wyoming . . . . . . . . . . 1-800-856-4398


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ESRD Networks by State

Alabama . . . . . . . . . . . 1-877-936-9260

Alaska . . . . . . . . . . . . . 1-800-262-1514

American Samoa. . . . 1-800-232-3773

Arizona . . . . . . . . . . . . 1-800-783-8818

Arkansas. . . . . . . . . . . 1-800-472-8664

Caliornia . . . . . . . . . . 1-800-637-4767

. . . . . . . . . . . . . . . . . . . 1-800-232-3773

Colorado. . . . . . . . . . . 1-800-783-8818

Connecticut . . . . . . . . 1-866-286-3773

Delaware. . . . . . . . . . . 1-800-548-9205

Florida. . . . . . . . . . . . . 1-800-826-3773

Georgia . . . . . . . . . . . . 1-800-524-7139

Guam . . . . . . . . . . . . . 1-800-232-3773

Hawaii . . . . . . . . . . . . . 1-800-232-3773

Idaho . . . . . . . . . . . . . . 1-800-262-1514

Illinois . . . . . . . . . . . . . 1-800-456-6919

Indiana . . . . . . . . . . . . 1-800-456-6919

Iowa. . . . . . . . . . . . . . . 1-800-444-9965

Kansas . . . . . . . . . . . . . 1-800-444-9965

Kentucky. . . . . . . . . . . 1-800-456-6919

Louisiana . . . . . . . . . . 1-800-472-8664

Maine . . . . . . . . . . . . . 1-866-286-3773

Maryland . . . . . . . . . . 1-866-651-6272

Massachusetts . . . . . . 1-866-286-3773

Michigan. . . . . . . . . . . 1-800-973-3773

Minnesota. . . . . . . . . . 1-800-973-3773

Mississippi . . . . . . . . . 1-877-936-9260

Missouri . . . . . . . . . . . 1-800-444-9965

Montana . . . . . . . . . . . 1-800-262-1514

Nebraska. . . . . . . . . . . 1-800-444-9965

Nevada . . . . . . . . . . . . 1-800-783-8818

New Hampshire . . . . 1-866-286-3773

New Jersey . . . . . . . . . 1-888-877-8400

New Mexico . . . . . . . 1-800-783-8818

New York . . . . . . . . . . 1-800-238-3773

North Carolina . . . . . 1-800-524-7139

North Dakota. . . . . . . 1-800-973-3773

Ohio . . . . . . . . . . . . . . 1-800-456-6919

Oklahoma . . . . . . . . . 1-800-472-8664

Oregon . . . . . . . . . . . . 1-800-262-1514

Pennsylvania . . . . . . . 1-800-548-9205

Puerto Rico . . . . . . . . 1-888-877-8400

Rhode Island . . . . . . . 1-866-286-3773

South Carolina . . . . . 1-800-524-7139

South Dakota . . . . . . 1-800-973-3773

ennessee . . . . . . . . . . 1-877-936-9260

exas . . . . . . . . . . . . . . 1-877-886-4435

Utah. . . . . . . . . . . . . . . 1-800-783-8818

Vermont . . . . . . . . . . . 1-866-286-3773

Virgin Islands . . . . . . 1-888-877-8400

Virginia . . . . . . . . . . . 1-866-651-6272

Washington . . . . . . . . 1-800-262-1514

Washington D.C. . . . . 1-866-651-6272

West Virginia . . . . . . 1-866-651-6272

Wisconsin. . . . . . . . . . 1-800-973-3773

Wyoming . . . . . . . . . . 1-800-783-8818


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50

Section 9: DefinitionsAssignmentAn agreement by your doctor or other supplier to be paid directly byMedicare, to accept the payment amount Medicare approves or the service, and not tobill you or any more than the Medicare deductible and coinsurance.

Benefit periodTe way that Original Medicare measures your use o hospital andskilled nursing acility (SNF) services. A benefit period begins the day you go into ahospital or skilled nursing acility. Te benefit period ends when you havent receivedany inpatient hospital care (or skilled care in a SNF) or 60 days in a row. I you go intoa hospital or a skilled nursing acility afer one benefit period has ended, a new benefitperiod begins. You must pay the inpatient hospital deductible or each benefit period.Tere is no limit to the number o benefit periods.

CoinsuranceAn amount you may be required to pay as your share o the cost orservices afer you pay any deductibles. Coinsurance is usually a percentage (or example,20%).

CopaymentAn amount you may be required to pay as your share o the cost or amedical service or supply, like a doctors visit, hospital outpatient visit, or a prescription.A copayment is usually a set amount, rather than a percentage. For example, you might

pay $10 or $20 or a doctors visit or prescription.

DeductibleTe amount you must pay or health care or prescriptions, beore OriginalMedicare, your prescription drug plan, or your other insurance begins to pay.

End-Stage Renal Disease (ESRD)Permanent kidney ailure that requires a regularcourse o dialysis or a kidney transplant.

GrievanceA complaint about the way your Medicare Health Plan or Medicare drugplan is giving care. For example, you may file a grievance i you have a problem callingthe plan or i youre unhappy with the way a staff person at the plan has behaved towardsyou. However, i you have a complaint about a plans reusal to cover a service, supply, orprescription, you file an appeal.

Medically necessaryServices or supplies that are needed or the diagnosis ortreatment o your medical condition and meet accepted standards o medical practice.


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51 Section 9Definitions

Medicare Advantage Plan (Part C)A type o Medicare health plan offered by aprivate company that contracts with Medicare to provide you with all your MedicarePart A and Part B benefits. Medicare Advantage Plans include Health MaintenanceOrganizations, Preerred Provider Organizations, Private Fee-or-Service Plans, SpecialNeeds Plans, and Medicare Medical Savings Account Plans.I youre enrolled in a Medicare Advantage Plan, Medicare services are covered throughthe plan and arent paid or under Original Medicare. Most Medicare Advantage Plansoffer prescription drug coverage.

Medicare-approved amountIn Original Medicare, this is the amount a doctoror supplier that accepts assignment can be paid. It includes what Medicare pays andany deductible, coinsurance, or copayment that you pay. It may be less than the actual

amount a doctor or supplier charges.

Medicare health planA Medicare health plan is offered by a private company thatcontracts with Medicare to provide Part A and Part B benefits to people with Medicarewho enroll in the plan. Tis term includes all Medicare Advantage Plans, Medicare CostPlans, Demonstration/Pilot Programs, and Programs o All-inclusive Care or the Elderly(PACE).

Original MedicareOriginal Medicare is ee-or-service coverage under which the

government pays your health care providers directly or your Part A and/or Part Bbenefits.

PremiumTe periodic payment to Medicare, an insurance company, or a health careplan or health or prescription drug coverage.

Secondary payerTe insurance policy, plan, or program that pays second on a claimor medical care. Tis could be Medicare, Medicaid, or other insurance depending on thesituation.


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52

IndexA

American Association o Kidney Patients #1American Kidney Fund #1Appeals #1, #2Assignment #1, #2

BBenefit Period #1, #2Blood Coverage #1, #2, #3

CChildren #1, #2, #3

Coinsurance #1, #2, #3, #4, #5, #6, #7

DDeductible #1, #2, #3, #4, #5, #6, #7Definitions #1Dialysis #1, #2, #3

Finding a dialysis acility #1ravel #1Whats covered #1Whats not covered #1

Dialysis Patient Citizens #1

EEmployer Group Health Plan #1, #2, #3Enrollment (Medicare) #1ESRD Networks #1, #2, #3, #4Extra Help #1

GGrievance (Complaints) #1, #2, #3, #4

HHMO #1

Home Dialysis reatment #1, #2, #3raining #1, #2, #3, #4

IImmunosuppressive Drugs #1, #2, #3
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53 Section 10Index

Kidney Organizations #1Kidney ransplant #1, #2

Drugs #1, #2Whats covered #1What you pay #1

MMedicaid #1Medicare Advantage Plans #1, #2, #3Medicare Coverage (Begins) #1Medicare Coverage (Ends) #1Medigap Policies #1

NNational Kidney and Urologic Diseases Inormation Clearinghouse #1National Kidney Foundation, Inc. #1

OOriginal Medicare #1, #2, #3, #4, #5, #6, #7, #8

PPancreas ransplant #1Part A (Hospital Insurance) #1, #2, #3,#4,#5, #6, #7Part B (Medical Insurance) #1, #2, #3, #4, #5, #6, #7, #8Phone Numbersor Help #1, #2

Premium #1, #2, #3, #4, #5, #6, #7

RRailroad Retirement #1, #2

SSecondary Payer #1, #2Social Security #1, #2,#3, #4Special Needs Plan #1, #2State Health Insurance Assistance Program (SHIP) #1, #2, #3, #4, #5, #6

Travel (Dialysis) #1

VVeterans Benefits #1

K
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


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U.S. DEPARMEN OF HEALHAND HUMAN SERVICES

Centers or Medicare & Medicaid Services7500 Security Boulevard

Baltimore, Maryland 21244-1850

Official BusinessPenalty or Private Use, $300

CMS Product No. 02174Revised May 2011

Tis booklet is available in Spanish. o get a reecopy, call 1-800-MEDICARE (1-800-633-4227).

Y users should call 1-877-486-2048.Necesita usted una copia en espaol?Para obtener su copia GRAIS, llame al1-800-MEDICARE (1-800-633-4227).

medicare & kidney services 2011.pdf

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