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.

I have an Employer Group Health Plan (EGHP)


If you are eligible for Medicare, your EGHP will be your primary insurance (pays first) for 30 months after starting dialysis or having a kidney transplant. This is called a coordination period. After 30 months, your EGHP will become your secondary insurance (pays second) and Medicare will become primary.

When should I apply for Medicare?

You can apply for Medicare when you first start dialysis or wait and apply closer to the end of the 30-month coordination period. Once you apply you will be responsible for the monthly Part B premiums. If you are planning to have a transplant and want Medicare to help pay for your immunosuppressant medications you will have to apply for Medicare part A and B when you become eligible. Insurance Choices for Dialysis and Transplant Patients with Private Insurance (Decision Aid)




I have Medicare


  • Medicare covers 80% of costs for dialysis treatment and 80% of the cost of immunosuppressant medications needed after transplant.

- - - - -

  • Do I need a supplemental insurance to help cover what Medicare doesn't?

    • Ideally, yes. There are a few coverage options:

      • Medigap Plans – you must apply for these plans within 6 months after you first become eligible for Medicare. They are available to anyone over 65 years old. Some states also offer these plans for people under 65. To find out what Medigap plans are available in your state, contact your State Health Insurance Assistance Programs (SHIPs).

      • Medicaid – need to qualify based on income. Income requirements vary by state.

Thinking about Transplant?

What other options do I have for Medicare plans?

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

  • Medicare Advantage – is 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.




I have insurance through my employer - do I need to apply for Medicare too?


If you have health insurance through your employer, you will be subjected to the Medicare Coordination of Benefits (COB) period. This means that your employee group health plan will pay for your dialysis treatment for 30 months and then Medicare will automatically become your primary insurance. If you choose to continue to keep your employee group health plan it would then become secondary to Medicare and could help pay the extra 20% not covered by Medicare part B.




I have Medicare only. Can I sign up for supplemental insurance through the Affordable Care Act Marketplace?


No, the Affordable Care Act Marketplace only provides primary insurance to people without any health insurance coverage. You may want to see if you are eligible for Medicaid, or contact the Illinois State Health Insurance Assistance Programs (SHIPs) to see if there are supplemental insurance policies available for you. If you would like personal help understanding Medicare A, B, D, and Medigap supplement plans, plus how to enroll in a suitable plan, contact your state's SHIP. These trained volunteers are experts in Medicare resources, and provide unbiased insurance counseling.




I applied for Medicare, when will my coverage begin?


The effective date of Medicare based on ESRD is dependent upon the type of treatment you choose:

  • For hemodialysis patients Medicare is effective the 4th month of treatment. For example:
    • If hemodialysis is begun in May, Medicare becomes effective August 1
  • For home dialysis patients Medicare is effective the first month of treatment
  • For transplant recipients Medicare is effective:
    • The month you're admitted to the hospital for a kidney transplant or for health care needed prior to a transplant if the transplant takes place that same month or within the following two months
OR
  • Two months prior to transplant if the transplant is delayed more than two months after you are admitted to the hospital in anticipation of transplant or related health services




How do I know if I have worked enough to qualify for Medicare?


You earn 1 work credit for earning a specific amount of money ($1,300 in 2017) from work in a 3-month quarter. The chart below gives a general guide to number of work credits needed to qualify for Medicare at a particular age. To find out how many work credits you have, call Social Security at 1-800-772-1213.




I have insurance through the Affordable Care Act Marketplace, should I apply for Medicare too?


If you have insurance through the ACA's marketplace, you do not need to sign up for Medicare unless you want to. You should evaluate your costs and coverage with the ACA plan vs Medicare. To help here is a Kidney Care Insurance Worksheet which is designed to help compare plans offered in the health insurance marketplaces established by the Affordable Care Act, so you can choose the most affordable and comprehensive plan. It is also important to note that if you apply for Medicare you will lose any subsidies you receive from your ACA Marketplace coverage. If you chose not to enroll in Medicare when your kidneys fail, you will have penalties with higher premiums if you chose to enroll later. Remember, Medicare only pays 80% of dialysis treatment so you will need a supplemental plan (Medigap) so you should also calculate this cost into your assessment. To find out what supplemental policies you qualify for, please contact the Illinois Health Insurance Assistance Programs (SHIPs).




I need help understanding insurance vocabulary


Here are defentions to some widely-used inurance language:

  • ACA Marketplace: The Affordable Care Act Health Insurance Marketplace, helps people without health coverage find and enroll in an insurance plan that fits your budget and meets your needs.

  • Balanced Billing - when a healthcare provider bills you for the difference between what your health insurance pays and what your provider charges.

  • Copayment (copay): Amount you may have to pay for healthcare or medications. A copay is often a fixed amount (for example $25).

  • Deductible: Amount you must pay for healthcare or medications before your insurance will pay.

  • Employer group health plan (EGHP): Coverage 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.

  • In-Network: Healthcare providers, practices, hospitals, etc. that are covered by your insurance plan. Choosing in-network providers is cheaper than out-of-network providers. To find a list of in-network providers contact your health insurance plan.

  • Medicaid: helps pay medical costs for people with low income and little savings. Medicaid can pay your Medicare premiums, deductibles, coinsurance and some costs Medicare doesn't cover.

  • Out of Network: Healthcare providers, practices, hospitals, etc. that are not as well covered by your insurance plan. It is cheaper to choose in-network providers instead of out-of-network providers. To find a list of in-network providers contact your health insurance plan.
  • Out of pocket maximum: The most you’ll have to pay during a period (usually a year). Once you reach the out of pocket maximum your plan pay 100% of covered services.
  • Premium: Amount to be paid monthly or quarterly to keep the health insurance plan active.




I have Medicaid


Medicaid should cover most of your dialysis and transplant expenses.

If you are undocumented, you may have a limited form of Medicaid coverage, often transplant is not covered.




I have private insurance through the Affordable Health Care Act (Obamacare).


You do not need to apply for Medicare at any time unless you choose to. If you choose to apply for Medicare, and your private insurance plan is through the Affordable Care Act, you will lose your private plan coverage. This is because Affordable Care Act insurance plans are for people who no other insurance options.

Once you have Medicare, you are considered to have other coverage and would no longer qualify for coverage through the Affordable Care Act.





 

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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