For Patients & Families: Insurance and Finance

insurance and finance

overview and introduction

learn about insurance options

Learning about insurance options and choosing a plan that is right for you can be confusing and overwhelming under the best of circumstances. If you are managing a diagnosis of kidney disease, especially if you are on dialysis or are considering a kidney transplant, there are be a few extra insurance-related elements you may want to know about - the most significant of which is the role that Medicare can play in your treatment.

 

Typically, Medicare is an insurance option for people over 65 years old - but there is a special entitlement that allows people who have kidney failure (also known as End Stage Renal Disease; or ESRD) to enroll. Medicare pays:

 

  • 80% of the cost of dialysis treatment

  • And 80% of the cost of immunosuppressant medications after transplant

 

In 1972, Medicare benefits were extended to cover the high cost of medical care for most individuals suffering from permanent kidney failure also known as end-stage renal disease (ESRD); people whose kidneys have failed and need dialysis or a kidney transplant to live. To this day, kidney failure is one of only two medical conditions that gives people the option to enroll in Medicare without a two-year waiting period, regardless of age. Because Medicare for people with ESRD was established separately and later, there are some specific rules around eligibility and coverage of Medicare for dialysis and transplant patients.

 

 

Please explore the following collection to learn more about insurance and find coverage resources.

 

insurance options: basics

Need help finding coverage? Or need to understand what coverage programs are? The following overview of basic coverage platforms can help get your started. Use the numbers and links below to connect with specialists, and find answers to any questions you may have.

The Affordable Care Act (ACA). 

Commonly known as Obamacare, the ACA helps people without health coverage find and enroll in an insurance plan that fits your budget and meets your needs. Find ACA resources below:

 

Medicaid 

Medicaid may also be an option for you if you meet income requirements.  Medicaid helps pay medical costs for people with low income and little savings. For people without insurance applying for coverage through the ACA - - the ACA website will also allow you to see if you qualify for Medicaid all in one application.

If you have Medicare, Medicaid can pay your Medicare premiums, deductibles, co-insurance and some costs Medicare doesn't cover.

Employee Group Health Plan (EGHP).  

Your company (or your spouse's company) may offer an employee group health plan (EGHP).  This means your healthcare coverage is sponsored by an employer or union.  If you either you, your spouse, or your parent (for children up to age 26) are working you may be eligible for insurance through your (their) employer. Employers with 50 full-time employees or more must offer insurance to their employees.

Over 65 or on dialysis or have a kidney transplant? 

Medicare helps Americans and legal residents of all ages who have worked and paid taxes into the system, and need dialysis or a kidney transplant. More than 90% of Americans with kidney failure, what Medicare calls End-Stage Renal Disease (ESRD), have Medicare.

 

 


Can't afford your medications?

Apply for Extra Help through Social Security.

 

  • You can apply online or call Social Security at (800) 772 - 1213 or visit your local social security office.

  • If you are enrolled in Medicare Part D you may be able to get help with your Medicare prescription drug plan costs. Help is based on your income.

  • If approved, you won't enter the Medicare Part D coverage gap ("donut-hole").

 

Co-pay assistance programs:

 

medicare and kidney failure

The following applies to people who receive Medicare ONLY because they have kidney failure. For those who are also eligible for Medicare based on age (over 65), or who have received Social Security Disability for 24 months, the following does not apply.

Patients who need dialysis are not eligible to sign up for Medicare (Parts A and B) until the day they begin dialysis. Once they sign up, Medicare will be effective at the beginning of their fourth month of dialysis and will start paying for their treatment if they choose in-center hemodialysis. For those who start dialysis at home—either peritoneal dialysis or home hemodialysis—Medicare coverage is effective on their first day of dialysis treatment.  Want to learn more about dialysis treatment options?  Click here.

 

Medicare also covers kidney transplants. After someone receives a successful kidney transplant, Medicare will continue to cover medical expenses for three years. Someone who receives a kidney transplant before needing to start dialysis (pre-emptive) can enroll in Medicare after the transplant and coverage will be retroactively effective to the day of the transplant. Three years after the successful transplant, Medicare coverage will end. People who receive a kidney transplant need to plan ahead to make sure they will have insurance coverage once their Medicare ends.

People with ESRD can enroll in the Affordable Care Act Marketplace plans: Can receive tax credits and subsidies (if they are financially eligible), but only if they do not enroll in Medicare.

If someone has health insurance through their employer or their spouse’s employer: that insurance plan will be primary (pays first) for 30 months starting the day his or her dialysis begins. After that, Medicare pays first, and their employer health plan will pay second.​

 

People eligible for Medicare: are generally not able to enroll in a Medicare Advantage plan, unless they had coverage from a plan owned by the same parent company prior to becoming eligible for Medicare.

Medigap plans (supplemental Medicare polices) are not available to ESRD patients in all states. This means if someone does not have another plan that will pay after Medicare, he or she may not be able to purchase any other supplemental policy and will be responsible for paying all deductibles and coinsurance. Medicare patients are responsible for a 20% coinsurance on most out-patient care.
 

If someone chooses not to enroll in Medicare: He or she doesn’t have to - but if they do not, they should also not enroll in Part A without Part B. (If they choose not to enroll in Medicare, they should not enroll in any part of Medicare).

 

save money on prescriptions

helping you stay healthy

The NKFI is proud to support the National Kidney Foundation Free Prescription Discount Carda patient service initiative managed by our national office in New York that focuses on ensuring families have affordable access to medication.

 

This totally free card offers you discounts on prescriptions - while helping fight kidney disease at the same time! Every time you save using the card, the National Kidney Foundation will receive a donation from our program partners at Watertree Health - at absolutely no cost to you. Meaning every time you take care of your own health, you help take care of other patients' help as well.

How does the card work? 

Show it to your pharmacist the next time you fill your prescription to receive savings of up to 75% (the average savings is 46% per prescription). 

 

What can I save on? And where can I save?

All brand name and generic drugs are eligible for savings. About 95% of pharmacies accept the card - you can look up the closest one here.

Can I use the card with insurance, Medicare or Medicaid?

It can't be combined with insurance plans/co-pays, but it is a great complement to them. Here's how:

 

  • If you have a high deductible, or you need to meet your deductible before your insurance pays for medications, the NKF Discount Card will start helping you save money right away.

  • Even if you have a low co-pay on brand name or generic medications (e.g., $10-15/per), the cost of the medication can be even cheaper with the card (e.g., $6/per). Savings can add up quickly if you use the card frequently. 

  • When you fill a prescription, you can have your pharmacist check the cost of the script with both the NKF card and your insurance - then apply the lower price. It’s that easy.

How do I get the card?

It’s simple. To instantly print, download, or get a card by email, click the link below - or text "KidneyRx" to 95577.

 

insurance and finance FAQ

basic facts and information

Use the following list to learn more about insurance, and find answers to some common questions related to managing finances and treatment.

 

other insurance options

Children's Health Insurance Program (CHIP)
Provides health coverage to children in families with incomes too high to qualify for Medicaid, but can't afford private coverage.

 

  • (877) KIDS-NOW / (877) 543-7669

 

COBRA

Allows an eligible employee who leaves a company to continue to be covered under the company’s health plan for a limited period of time for a higher premium.

 

Indian Health Services

A Federal Health Program for American Indians and Alaska Natives.

 

Medicare Advantage
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. People with ESRD are not eligible to apply for these plans, but some may already be enrolled in a Medicare Advantage plan before starting dialysis or needing a transplant.

Medigap Plans
Supplemental plans for Medicare recipients that helps cover what traditional Medicare does not, such as copayments, coinsurance, and deductibles. This includes the 20% not covered by Medicare Part B for outpatient services (i.e. dialysis) and immunosuppressant medication for transplant recipients. You can sign up for a Medigap plan in the six-month period after you enroll in Medicare.

Managed Care Plans
Some states are offering pilot programs enrolling people who are eligible for both Medicare and Medicaid.

 

TRICARE

Serves Uniformed Service members, retirees and their families worldwide.

US Department of Veterans Affairs

Apply for compensation, pension, education or vocational rehabilitation benefits on-line if you are a veteran. The VA can help pay for treatment or provide other benefits for veterans. Veterans should contact their local VA office for more information or call 1-800-827-1000 to reach the national office..

 

LEARN ABOUT LIVING WITH KIDNEY DISEASE

NKFI kidney health resources

The information shared on this website has been reviewed by staff at the New York City headquarters of the National Kidney Foundation. Please note: material contained here are intended solely for reference. This material does not constitute medical advice; it is intended for informational purposes only. If you feel you need professional medical care, please consult a physician for specific treatment recommendations.

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