Financial and Resource Information

Transcription

1 Patient Education Chapter 9 Page 1 Financial and Resource Information Objectives: 1. Know where to obtain more information about financial resources. 2. Understand importance of knowing about insurance coverage and other resources, when needed. Each health insurance policy is different. Review your plan so you know: What things are covered. What percentage of the costs are covered. Some people with kidney disease can qualify for: Social Security Disability (SSDI). Supplementary Security Income (SSI). Public Assistance. Social workers and financial counselors can help you figure out your insurance needs. Your dialysis center and transplant center have these specialists on staff to help you. American Nephrology Nurses Association Greater Puget Sound Chapter

2 Chapter 9 Page 2 Many people are concerned about how kidney disease will affect their finances. Here is information about: Income sources. Who covers the cost of dialysis. Other services that offer help with costs related to kidney disease. Even though you may not need this information now, keep it in case you need to refer to it at a later time. Income Sources Social Security Disability (SSDI) Call or visit the local Social Security Office in person to apply. 1. Call to request an appointment to file an application for benefits with the local office. a. The office hours are 7:00 a.m. to 8:00 p.m. b. The best times to call are before 8:00 a.m. and after 5:00 p.m. c. Avoid calling on a Monday and during the first week of any month. 2. When you contact the 800 number, they will schedule an appointment. They will send you a packet of information about the disability program. Some of the forms in the packet must be completed and returned to the local office right away and prior to your visit. They will ask for information about your disability and for names and addresses of any and all medical resources. Brochures that explain Social Security, Social Security Disability and Supplemental Security Income can be obtained through the 800 number. Benefits begin the fifth month the person is found to have met the requirements. a. If the application is made more than 6 months after the individual is deemed disabled, retroactive payments may be made for up to 12 months. b. Additional benefits may be paid to dependents of disabled persons. c. The amount of the monthly benefit is based on earnings you had made while working. d. You must have worked and paid into Social Security for 5 out of the last 10 years to be eligible.

3 Chapter 9 Page 3 Supplemental Security Income (SSI) 1. The application is made the same way as for Social Security Disability. 2. Persons who may qualify include those who are: a. 65 years or older. b. 18 years or older if a physical or mental disability is expected to keep him or her from working for at least 12 months or if it could result in death. c. Under the age of 18 with a disability as severe as one that would keep an adult from working for at least 12 months, or if it could result in death. 3. There are income and resource limits for this program which are detailed in the SSI information brochure. 4. If you apply and are granted SSI, you are entitled to Medicaid through the Department of Social and Health Services (DSHS). Take proof of your SSI award to your local DSHS Office. Other programs for which you may qualify through DSHS include Public Assistance, Aid to Families with Dependent Children (AFDC) and Food Stamps. There are income and resource guidelines for each of these programs. Sources of Payment for Medical Services When You Have Kidney Failure Medicare People who qualify for Medicare include individuals, spouses, or parents of a minor child with 10 years of earnings under Social Security or Civil Service, or 6 quarters out of the last Medicare effective date. a. The first day of the third month after the month dialysis starts. For example if you started dialysis 2/6/2004, the Medicare effective date would be 5/1/2004. b. If the person opts for home dialysis, the training for home dialysis begins during the waiting period for Medicare. Medicare will be effective the first day of the month in which dialysis begins. For example, if you started dialysis 4/30/2004 and started training for home dialysis 6/15/2004, the Medicare effective date would be 4/1/2004.

4 Chapter 9 Page 4 c. The first day of the month, the person enters the hospital in preparation for kidney transplant if the transplant occurs that month or in the next two months. For example, if you were admitted to the hospital on 2/6/2004 and were transplanted 2/16/2004, the Medicare effective date would be 2/1/ If the person is eligible for Medicare only because of End Stage Renal Disease (ESRD), Medicare will stop: a. The first of the thirteenth month after dialysis ends. For example if your last dialysis treatment was 6/6/2004, Medicare would stop 7/1/2005. b. Thirty-six months after a successful kidney transplant. For example, if you received a transplant 7/8/2004 your Medicare coverage will stop 7/31/2007. c. If you fail to pay the premium, or if you cancel the coverage. d. If the person is eligible for Medicare because of Age or Disability, Medicare will continue uninterrupted under appropriate benefit. 3. Medicare Hospital Insurance (Part A) that pays for inpatient hospital stays is available without a monthly premium. Medicare insurance (Part B), the part that pays for dialysis and other out-ofhospital services, has a monthly premium which is adjusted each year on January 1. a. If the person receives a monthly Social Security or Civil Service benefit (Retirement or Disability), the premium is deducted from the person s check. b. If the person is eligible for Medicaid, the Medi-award letter or card must be taken to the Community Service Office so Medicaid will pay the premium. c. Otherwise, the person will be billed quarterly. 4. Medicare covers hospital services in full after a benefit period deductible. Out-of-hospital services are covered at 80% of the allowed amount after the annual deductible is met. 5. Transplant costs. a. Living Related Donor 1) Diagnostic charges for all potential donors, no matter where performed, are billed to the transplant program the recipient is registered with.

5 Chapter 9 Page 5 2) The hospital bill for the transplant will be added to the recipient s bill and billed to Medicare. 3) The donor has no financial liability other than transportation to the transplant hospital, and possible work time loss. 4) The recipient s bill is handled as any other medical bill. b. Cadaver Donor 1) Costs to retrieve, maintain, test, and transport the kidney to the transplant hospital are added to the recipient s hospital bill as the Kidney Acquisition Charge and are billed to Part A of Medicare. 2) All recipient s charges, whether to determine a suitable donor or for the surgery, are billed as any other medical bill. c. Medicare Part B will cover a portion of anti-rejection medication for 36 months after transplant. It is paid at 80% of what Medicare allows. 6. Medicare is most often the primary payer. a. It pays before other Federal and State programs (excluding insurance through employment). b. If a patient receives Medicare based on Chronic Renal Failure policy and has insurance through an employer group plan, the insurance will be primary for the first 30 months of Medicare eligibility whether or not the patient signs up for Medicare. c. If a patient already has Medicare because of age or disability and has insurance through an employer group plan, the insurance will be primary for 30 months if the subscriber is working. If the subscriber is not working, Medicare becomes primary when the patient starts dialysis. The 30-month period is figured as though the patient did not previously have Medicare. 7. What Medicare does not cover. a. Out-patient medications. b. Nutritional supplements. c. Transportation to and from dialysis. Private Insurance 1. Employment related group coverage of the individual, spouse, or parent. 2. Commercial Medicare supplements if the person is over age 65.

6 Chapter 9 Page 6 3. Medicare supplement through the Washington State Health Insurance Pool ( ). a. Person must not be Medicaid eligible. b. Must not be eligible for other insurance or must have limited benefits, or premium substantially increased. c. It has a 3-month wait for chronic and pre-existing conditions, unless application is made within 30 days of termination of other insurance. d. Premium is based on sex, age, and zip code. Department of Social and Health Services 1. Pays balances after other sources have been exhausted on those individuals deemed eligible. 2. Person must apply at the local Community Service Office and provide all information asked for to determine eligibility. 3. Some may be responsible for a monetary spend down before assistance will be granted. 4. Most times, a person has to reapply every three months to maintain eligibility. 5. Pays the Medicare premium for its recipients. 6. In most cases, covers outpatient medications, transportation, and nutritional supplements. Washington State Kidney Disease Program (KDP) 1. For those persons with limited assets and income who are not eligible for Medicaid, or cannot afford the premium for a Medicare supplement. 2. Depending on the family size and income, it pays in full after other sources or after an annual KDP deductible has been reached. 3. It covers only kidney-related expenses and prescriptions, not those incurred for contributory conditions such as diabetes and hypertension. 4. Prescriptions must be included in the state formulary to be covered. 5. Must apply first to DSHS to get a definitive Medicaid determination.

7 Chapter 9 Page 7 Champus 1. Available to active duty military personnel and their dependents. 2. Available to retired military personnel and their dependents. a. Champus changes dramatically when Medicare becomes effective. The changes differ based on reason for Medicare eligibility. Keep the letters you receive from Medicare stating the reasons for your eligibility. Champus needs them to determine your benefits. Without them, Champus will pay at the lowest benefit level (usually zero). b. Some Champus plans require an authorization for treatment. Champus will not do a retroactive referral so be sure to check your benefit booklet to see if one is required. Veteran s Administration (VA) 1. The VA provides long term in-center dialysis. No co-payments are required at the VA. 2. It provides for kidney transplants either through a VA facility, which does transplants or through transplant programs in the region. 3. Transplants are not done at the Seattle VA. 4. All services must be approved by VA in advance. VA will usually only approve services for illnesses that are service related. Indian Health Services does NOT provide long-term dialysis or transplants. Services Available Through Public Donation Northwest Kidney Centers Foundation 700 Broadway, Seattle, WA The Foundation manages an Emergency Fund program to assist patients having a temporary financial crisis. To learn more, contact a social worker in a participating dialysis facility. 2. The Foundation has a limited number of Rehabilitation Scholarships for patients seeking academic or vocational training in order to enter, or reenter the work force. Contact Northwest Kidney Centers to learn more.

8 Chapter 9 Page 8 Questions? Your questions are important. Call your doctor or health care provider if you have questions or concerns. 3. The Foundation s Car Buddies program provides volunteer transportation to senior citizens (60 years or older) in King County needing temporary rides to their dialysis appointments. The Foundation coordinates the program for Northwest Kidney Centers, but will help other facilities start a similar program. 4. The Foundation provides patient education materials. To request a list of these materials, contact the Northwest Kidney Centers (see contact information on page 7). 5. The Foundation provides annual grants to other facilities and organizations for activities such as an annual patient education workshop and OUTPUT, a monthly patient newsletter. American Kidney Fund Patient Services Department 6110 Executive Blvd., Suite 1010, Rockville, MD The American Kidney Fund has a grant program that helps defray costs for temporary treatment related needs such as: a. Medicine. b. Transportation. c. Dietary needs. d. Insurance and Medicare premiums. 2. It does not help with hospitalization. 3. Funding is based on the availability of funds at the time of application. 4. It is accessed through the dialysis center or hospital social worker who submits the application. Every attempt has been made to provide you with correct information. Because government programs and insurance policies change, we strongly suggest you verify your coverage. Each Social Security Office has information for you about current benefits and premiums. If you have Medicaid coupons, your financial worker at DSHS can verify current benefits. Insurance benefits can be confirmed by calling your insurance company s customer service department. The phone number should be listed on your insurance card. Of course, we cannot guarantee how benefits will be paid by any program or insurance policy. American Nephrology Nurses Association Greater Puget Sound Chapter University of Washington Medical Center 07/2004