A Factsheet from Social Security _______________________________________________________________ U.S. Department of Health and Human Services Social Security Administration SSA Publication No. 05-10013 April 1994 Medicare For People Who Have Permanent Kidney Failure If you need dialysis treatments for permanent kidney failure or a kidney transplant, you may be eligible for Medicare--no matter what your age. This factsheet gives a brief overview of how you qualify and the benefits available. For more in-depth information, ask Social Security for a copy of the booklet, "Medicare Coverage of Kidney Dialysis and Kidney Transplant Services". Who is Eligible? If you have begun a regular course of dialysis or have had a kidney transplant, you are eligible for Medicare if: * you are receiving Social Security or Railroad Retirement benefits; or * you have worked long enough under the Social Security or railroad retirement programs or in Medicare covered government employment to be insured for Medicare; or * you are the spouse or dependent child of someone who meets either of the above requirements. What Will Medicare Pay For? Medicare has two parts: hospital insurance (Part A) and medical insurance (Part B). Part A helps pay for inpatient hospital costs associated with kidney transplant surgery. Part B helps pay for regular dialysis as an outpatient and helps pay for other services, including surgeons' fees for transplant surgery, laboratory tests, home dialysis equipment, and the supplies and other services associated with such treatment. What Else Does Medicare Cover? If you are enrolled in Medicare because of permanent kidney failure, you have the same coverage as anyone else who is on Medicare. That means Medicare will help pay for other hospital and medical services you may need even if they are unrelated to your kidney disease. For a detailed explanation of the coverage and services available from Medicare in general, ask Social Security for a copy of "The Medicare Handbook". How Much Will Medicare Cost? You pay nothing for Part A coverage until you enter a hospital. The first time you enter a hospital in 1994, you'll be responsible for the first $676 of your bill. After 60 days in the hospital, you'll have to pay additional charges. There's a monthly premium ($36.60 in 1993) for Part B and a $100 annual deductible. After you meet the deductible, Medicare generally pays about 80 percent of the Medicare-approved amount for services and supplies. You have to pay the rest. If you have low income and few resources, your State may pay your Medicare premiums and, in some cases, other "out-of-pocket" Medicare expenses such as deductibles and coinsurance. Only your State can decide if you qualify. To find out if you do, contact your State or local welfare office or Medicaid agency. For more general information about the program, contact Social Security and ask for a copy of the factsheet, "Help For Low Income Medicare Beneficiaries" (Publication No. 05-10079). When Will Your Medicare Coverage Begin? If you are eligible for Medicare due to permanent kidney failure, the date that your coverage begins depends on the kind of medical treatment your condition requires. If you are receiving regular dialysis treatments, your Medicare coverage starts the third month after the month your regular dialysis treatments begin. For example, if you began receiving regular dialysis treatments in July, your Medicare coverage would start on October 1. There Are Two Ways Medicare Coverage May Begin Earlier 1) Coverage may begin in the first month of dialysis if: * you participate in a self-dialysis training program in a Medicare-approved training facility; and * you start the training before the third month after dialysis begins; and * you expect to complete the training and self-dialysis, thereafter. 2) Coverage may begin the month you are admitted to an approved hospital for a kidney transplant or procedures preliminary to a transplant if the transplant takes place in that month or within the following months. To find out exactly when your coverage would begin, contact a Social Security office. When Would Medicare Coverage End? If you are enrolled in Medicare due to permanent kidney failure, your coverage would end one year after the month you stop regular dialysis treatments or three years after the month of kidney transplant. However, if you resume dialysis or have another kidney transplant, your coverage would be continued or reinstated immediately. Who May Provide Dialysis And Transplant Surgery? To receive Medicare payments, a medical institution must be specifically approved by the federal government to administer kidney dialysis or transplant surgery. This is true even if it is already certified by Medicare to provide other health care services. Representatives of the institution, or your doctor, will be able to tell you whether a facility is approved by Medicare for dialysis and transplant services. What About HMOs? Many Medicare beneficiaries are choosing to enroll in prepaid managed care plans, primarily health maintenance organizations (HMOs). If you have permanent kidney failure, you cannot enroll in a Medicare HMO. However, if you develop permanent kidney failure after joining an HMO, the plan will provide for, pay for, or arrange for your care. How Do You Apply For Medicare And Where Do You Get Information? Once you begin a regular course of kidney dialysis or have had kidney transplant surgery, you should apply for Medicare by contacting your Social Security office. You can get more information, including the other booklets mentioned in this factsheet, from Social Security. Or, set up an appointment for an interview by calling Social Security's toll-free number, 1-800-772-1213 any business day between 7 a.m. and 7 p.m. The best times to call are early in the morning, late in the afternoon, late in the week, and toward the end of the month. The Social Security Administration treats all calls confidentially--whether they're made to our toll-free number or to one of our local offices. We also want to ensure that you receive accurate and courteous service. That is why we have a second Social Security representative listen to some incoming and outgoing telephone calls