Section 2: Kidney Dialysis
What is dialysis?
Dialysis is a treatment that cleans your blood when your kidneys don’t work. It gets rid of harmful waste, extra salt, and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids. Dialysis treatments help you feel better and live longer, but they aren’t a cure for permanent kidney failure.
Dialysis treatment options
There are 2 types of dialysis treatment options:
1. Hemodialysis uses a special filter (called a dialyzer) to clean your blood. The filter connects to a machine. During treatment, your blood flows through tubes into the filter to clean out wastes and extra fluids. Then the newly-cleaned blood flows through another set of tubes back into your body.
2. Peritoneal dialysis uses a special solution (called dialysate) that flows through a tube into your abdomen. After a few hours, the dialysate has taken wastes from your blood and can be drained from your abdomen. After draining the used dialysate, your abdomen is filled with fresh dialysate, and the cleaning process begins again.
You should work with your health care team to decide the type of dialysis you need based on your situation. The goal is to help you stay healthy and active.
Dialysis services and supplies covered by Medicare
Medicare covers the following dialysis services and pays part of their costs: Service or supply covered by Medicare Part A:
■ Inpatient dialysis treatments (if you’re admitted to a hospital for special care) Service or supply covered by Medicare Part B:
■ Outpatient dialysis treatments (if you get treatments in any Medicare-approved dialysis facility)
Outpatient doctors’ services (more info)
■ Self-dialysis training (includes instruction for 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 info)
■ Certain home support services (may include visits by trained hospital or dialysis facility workers to check on your home dialysis, to help in emergencies when needed, and to check your dialysis equipment and water supply) (more info)
■ Most drugs for home dialysis (more info)
■ Other services and supplies that are a part of dialysis (like laboratory tests) To find out what you pay for these services, see more info.
Home dialysis services and supplies NOT covered by Medicare
Medicare doesn’t cover the following 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 self-dialysis training
■ A place to stay during your treatment
■ Blood or packed red blood cells for home self-dialysis unless part of a doctors’ service
There are some types of insurance that may pay some of the health care costs that Medicare doesn’t pay. More info. For more information on Medicare prescription drug coverage, see more info.
Medicare payment system for dialysis services
A new payment system called the ESRD Prospective Payment System (PPS) went into effect on January 1, 2011. This payment system “bundles” or combines all of the Part B
ESRD dialysis services and items that were previously grouped under the composite rate and those ESRD dialysis items or services that were previously billed separately.
The composite rate is the former method that Medicare used to pay dialysis facilities for dialysis-related services.
What’s included in the new payment system
The new payment system includes the following Part B covered services and items:
■ Dialysis-related services, equipment, and supplies that were in the prior composite rate
■ Injectable drugs and their oral forms and biologicals, including erythropoiesis stimulating agents used for ESRD dialysis treatment*
■ Laboratory tests and other items and services provided for ESRD dialysis treatment
■ Home dialysis training by a Medicare-certified home dialysis training facility (if you choose to get dialysis at home)
*Medications that are only available in oral form will continue to be covered under Medicare prescription drug coverage (Part D). Talk with your doctor or health care team about the use of any drugs, including over-the-counter products.
What YOU pay for dialysis services in a dialysis facility under the new payment system
If you have Original Medicare, you’ll continue to pay 20% of the Medicare-approved amount for all covered dialysis related services. Medicare will pay the remaining 80%. The amount (20%) for which you’re responsible may vary under the new payment system.
If you’re in a Medicare Advantage Plan (like an HMO or PPO) or have a Medicare Supplement Insurance (Medigap) policy that covers all or part of your 20% coinsurance, then your costs may be different. Read your plan materials or call your benefits administrator to get your cost information. You must also continue to pay your monthly Part B and Part D (if applicable) premiums.
Note: Your 20% copayment covers all of the services and items listed here. Since these services and items are included in the new bundled payment system, you can’t be billed separately for them. You also don’t need to get the drugs that are included in the bundle from your Medicare drug plan (if you have one).
Medicare payment for children with ESRD
If you have a child under 18 who has Medicare coverage because of ESRD, the payment rules are the same as described above. However, the rates paid to the dialysis facilities are adjusted based on the child’s age and the type of dialysis they get. These adjustments allow for the special care needs of children.
Training for self-dialysis at home
Training for self-dialysis at home is covered under Part B on an outpatient basis, but only in a facility certified for dialysis training. You may qualify for training if you think you would benefit from self-dialysis training for at-home treatments, and your doctor approves. Training sessions will occur at the same time you get dialysis treatment and are subject to a maximum number of sessions.
Doctors’ self-dialysis training services
In Original Medicare, Medicare pays your kidney doctor a flat fee to supervise self-dialysis training. After you pay the Part B yearly deductible ($140 in 2012), Medicare pays 80% of the flat fee and you pay the remaining 20%.
Example: (What you pay may be different than what’s shown.)
Let’s say the flat fee for the doctor who’s supervising the self-dialysis training is $500.
After you pay the Part B yearly deductible, here are the costs:
■ Medicare pays 80% of the $500 (or $400).
■ You pay the remaining 20% coinsurance (or $100).
Home dialysis
Your dialysis facility will be responsible for providing all of your home dialysis related items and services including equipment and supplies (either directly or under arrangement). Under the new payment system, home dialysis equipment and supplies provided directly from dialysis suppliers (formerly referred to as Method II) are no longer available. However, dialysis suppliers may provide equipment and supplies under arrangement with your dialysis facility. Medicare pays for home dialysis at the same rate as dialysis you get in a facility.
Monthly doctor visits for home dialysis
Medicare pays doctors (and certain non-doctors, such as physician assistants and nurse practitioners), on a monthly basis, to help people with Medicare who perform self-dialysis at home manage their care. This benefit includes a face-to-face visit between you and your doctor once a month. The face-to-face visit allows you and your doctor to discuss your care and the effectiveness of your dialysis, to check for complications, and to give you a chance to ask questions about your home dialysis treatment.
How long will Medicare pay for home dialysis equipment?
Part B will pay for home dialysis equipment as long as you need dialysis at home. If you no longer need home dialysis (for example, if you had a kidney transplant), Part B would stop paying.
Dialysis in a hospital
If you’re admitted to a hospital and get dialysis, your treatments will be covered by Part A as part of the costs of your covered inpatient hospital stay.
Inpatient doctors’ services
In Original Medicare, your kidney doctor bills separately for the Medicare-covered ESRD services you get as an inpatient. In this case, your kidney doctor’s monthly payment will be based on the number of days you stay in the hospital.
Outpatient doctors’ services
In Original Medicare, Medicare pays most kidney doctors a monthly amount. After you pay the Part B yearly deductible ($140 in 2012), Medicare pays 80% of the monthly amount. You pay the remaining 20% coinsurance.
In some cases, your doctor may be paid per day if you get services for less than 1 month.
Example: (What you pay may be different than what’s shown.)
Let’s say the monthly amount that Medicare pays your doctor for each dialysis patient is $125. After you pay the Part B yearly deductible, here are the costs:
■ Medicare pays 80% of the $125 (or $100).
■ You pay the remaining 20% coinsurance (or $25).
Where to get dialysis treatments
Dialysis can be done at home or in a Medicare-certified dialysis facility. For Medicare to pay for your treatments, the facility must be approved by Medicare to provide dialysis (even if the facility already provides other Medicare-covered health care services).
At the dialysis facility, a nurse or trained technician may give you the treatment. At home, you can treat yourself or you can ask a family member or friend for help. If you decide to do home dialysis, you and your helper (if you have one) will get training.
If you have a problem with the care you’re getting from your dialysis facility, you have the right to file a grievance (complaint) to resolve your problem. See here, “Filing a grievance (complaint),” for more information.
How to find a dialysis facility
In most cases, the facility your kidney doctor works with is where you will get dialysis treatments. However, you have the right to choose to get your treatments from another facility at any time, but this could mean changing doctors.
You can also call your local ESRD Network (more info) to find a dialysis facility that’s close to you, or you can use “Dialysis Facility Compare” by visiting www.medicare.gov/ dialysis.
“Dialysis Facility Compare”
“Dialysis Facility Compare” has important information about Medicare-certified dialysis facilities in your area and around the country. Visit www.medicare.gov/dialysis. You can find information such as addresses and phone numbers, how far certain facilities are from you, and what kind of dialysis services the facilities offer. You can also compare facilities by the services they offer and by certain quality of care information. Helpful Web sites, publications, and phone numbers are also available. You can discuss the information on this Web site with your health care team.
If you don’t have a computer, your local library or senior center may be able to help you look at this information. You can also call 1-800-MEDICARE (1-800-633-4227), or contact your local State Health Insurance Assistance Program (more info) to get help with comparing dialysis facilities. TTY users should call 1-877-486-2048.
Knowing how well your dialysis is working
With the right type and amount of dialysis, you’ll probably feel better and less tired, have a better appetite and less nausea, have fewer hospital stays, and live longer.
You can tell how well the dialysis is working with blood tests that keep track of your URR or Kt/V (pronounced “kay tee over vee” ) number. These numbers tell your doctor or nurse how well dialysis is removing wastes from your body. Your doctor or nurse usually keeps track of one or both of these numbers, depending on which test your dialysis facility uses.
A URR of 65% and a Kt/V of 1.2 are the minimum numbers for adequate dialysis. Your health care provider or dialysis center may set a higher dialysis goal for your health and to make you feel better. Talk to your health care provider about your number.
Even if you feel fine, you should still check how well your dialysis is working.
For a short period of time, you may feel okay without adequate dialysis. However, over time, not getting adequate dialysis can make you feel weak and tired. It can lead to a higher risk of infection and prolonged bleeding. It can shorten your life.
Here are some steps you can take to get adequate dialysis:
■ Go to all of your scheduled treatments and arrive on time.
■ Stay for the full treatment time.
■ Follow your diet and fluid restrictions.
■ Follow the advice of your dialysis staff on taking care of yourself.
■ Check your URR or Kt/V adequacy number every month.
■ Talk to your doctor about which hemodialysis vascular access* is best for you.
■ Learn how to take care of your vascular access.
To learn more about how well your dialysis is working, talk with your doctor or other health team members at your dialysis facility.
* Your vascular access is the entrance your doctor makes into your blood vessels. During dialysis, your blood is removed and returned through your vascular access.
Dialysis when you travel
You can still travel within the United States if you need dialysis. There are over 5,000 dialysis facilities around the country. Your facility can help you plan your treatment along the route of your trip before you travel. Your dialysis facility will help you by checking to see if the facilities on your route:
■ Are approved by Medicare to give dialysis
■ Have the space and time to give care when you need it
■ Have enough information about you to give you the right treatment
In general, Medicare will only pay for hospital or medical care that you get in the United States.
Note: If you get your dialysis services from a Medicare Advantage Plan, your plan may be able to help you arrange to get dialysis while you travel. Contact your plan for more information.
Transportation to dialysis facilities
Medicare covers ambulance services to and from your home to the nearest dialysis facility for treatment of ESRD only if other forms of transportation would be harmful to your health.
For non-emergency, scheduled, repetitive ambulance services, the ambulance supplier must get a written order from your doctor before you get the ambulance service. The doctor’s written order must certify that ambulance transportation is medically necessary and must be dated no earlier than 60 days before you get the ambulance service.
If you’re 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 plan for more information.
For more information about ambulance coverage, visit www.medicare.gov/publications to read or print the booklet “Medicare Coverage of Ambulance Services.” You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Visit www.medicare.gov/dialysis to get information about Medicare-certified dialysis facilities in your area.
