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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.

Basics

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).

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.

Watertree-card-final.jpg

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.

Card

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.

  • Why are the kidneys so important?
    Your kidneys perform important functions that affect every part of your body. In fact, many other organs depend upon the kidneys to function normally. The kidneys perform complicated jobs that keep the rest of the body in balance. When the kidneys become damaged, your body’s other organs are affected as well. The major job of the kidneys is to remove waste products and extra fluids from the body in the form of urine. The production of urine is a complicated process that maintains a chemical balance in your body. Your kidneys also regulate your body’s salt, potassium and acid content, and make hormones that affect the way your other organs function. One hormone produced by the kidneys is needed to make red blood cells. Others help regulate your blood pressure and help your body use calcium. Your kidneys also: Remove waste products from your body Balance chemicals in your body, such as potassium, phosphorus, calcium, and sodium Balance your body’s fluids Regulate your blood pressure Promote strong, healthy bones
  • How do your kidneys work / function?
    Each of your two kidneys contains about one million functioning units called nephrons. A nephron consists of a filtering unit of tiny blood vessels, called a glomerulus, which is attached to a tubule. When blood enters the glomerulus, it is filtered and the remaining fluid then passes through the tubule. In the tubule, chemicals and water are either added to or removed from this filtered fluid according to the body's needs. The final product is urine, which we excrete. The kidneys perform their life-sustaining job of filtering and returning to the bloodstream about 200 quarts of fluid every 24 hours. Approximately two quarts are eliminated from the body in the form of urine, and about 198 quarts are retained in the body. The urine we excrete has been stored in the bladder anywhere from 1 to 8 hours.
  • What is chronic kidney disease?
    Chronic kidney disease (CKD) means the kidneys are damaged. When the kidneys are damaged, they cannot filter blood and do their other jobs well enough. Protein in the urine for three months or longer is a warning sign of kidney damage. Your level of kidney function is measured by the test for glomerular filtration rate (GFR). A GFR of less than 60 for three months or more indicates CKD.
  • What are some of the types and causes of kidney disease?
    There are many types of kidney disease, and it usually affects both kidneys. If the kidneys' ability to filter the blood is damaged by disease, wastes and excess fluid may build up in the body, causing severe swelling and symptoms of kidney failure. The kidneys may be affected by diseases such as diabetes and high blood pressure. Some kidney diseases are inherited Other diseases are congenital; that is, individuals may be born with an abnormality that can affect their kidneys. The following are some of the most common types and causes of kidney disease: Diabetes is the leading cause of serious kidney disease. High blood pressure (also known as hypertension) is another common cause of kidney disease. Glomerulonephritis is a disease that causes inflammation of the kidney's tiny filtering units, the glomeruli. Polycystic kidney disease is the most common inherited kidney disease. Kidney stones are a common kidney malady that can cause further damage to the kidneys if they are not treated. Urinary tract infections occur when bacteria enter the urinary tract and cause symptoms such as pain and/or burning during urination and more frequent need to urinate. Congenital diseases such as Goodpasture's Syndrome and Reflux Disorder may also affect the kidneys. Overuse of over-the-counter medications and the use and buildup of illegal drugs in the body can cause kidney failure. To learn more about kidney disease, please click here.
  • How is kidney disease detected?
    Early detection and treatment can slow or prevent the progression of kidney disease. Some simple tests can be done to detect early kidney disease. They are: Blood pressure monitoring. High blood pressure is a cause of kidney disease. It may also be a sign of kidney trouble. A test for protein in the urine. Too much protein in your urine may mean that your kidneys’ filtering units have been damaged. A single positive result could be due to a fever or heavy exercise, so your doctor will want to confirm your urine protein test results over several weeks. An estimate of your Glomerular Filtraion Rate (GFR) to show how much kidney function you have. Your doctor uses the results of a blood test, along with your age, gender, and race, to estimate your GFR number. This number tells your doctor how much kidney function you have. As CKD progresses, your GFR number decreases. A completely healthy kidey function is measured at a GFR of around a 100, which means that the kidneys are working at 100 percent. Your kidney function is still considered normal if the GFR number is 90 or greater. Here's a way to understand the GFR scale: If your GFR is 45, you know that your kidneys are working at approximately 45 percent of the normal rate. It is very important that people who are at increased risk for kidney disease have these tests.
  • Can kidney desease be treated?
    Many kidney diseases can be treated. Careful control of diseases like diabetes and high blood pressure can help to prevent kidney disease or slow its progression. Kidney stones and urinary tract infections often can be treated successfully. Unfortunately, the exact causes of some kidney diseases are still unknown, and specific treatments are not yet available. Sometimes these diseases progress to chronic kidney failure, requiring dialysis or kidney transplantation. Changes in diet and treatment for high blood pressure sometimes help to slow the progression of these diseases. Research is being conducted to find more effective treatment for these diseases.
  • If I have chronic kidney disease, do I need dialysis?"
    Ultimately, dialysis is treatment option that is entirely up to the patient. Normally, dialysis is not considered as a treatment option unless a patient is expereincing end-stage kidney failure (which usually occurs when a patient loses about 85 to 90 percent of their kidney function, and they have a GFR of less than 15). If you are not in end-stage kidney failure, your physician will likely work to slow, or control, the cause of your kidney disease. Treatment options vary, depending on the cause. But kidney damage can continue to worsen even when an underlying condition, such as high blood pressure, has been controlled. Your doctor will likely also work to treat any complications that arise from kidney disease. Treatments may include: High blood pressure medications Medications to lower cholesterol levels Medications to treat anemia Medications to relieve swelling Medications to protect your bones A lower protein diet to minimize waste products in your blood
FAQ

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..

Other Options

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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