Public health insurance

These plans are funded by the government and help certain groups of people:

• Medicare: Medicare is a federal health insurance program for people who are 65 years of age or older, or who have certain disabilities or kidney failurealso called end-stage renal disease (ESRD) or end-stage kidney disease (ESKD). There are different parts of Medicare that cover different types of care, including hospital stays and prescription drugs.
• Medicaid: Medicaid is a government program that provides free or low-cost health coverage to people with limited income and resources. It covers eligible adults, children, pregnant women, older adults and people with disabilities. Medicaid rules and benefits vary from state to state. Many people with kidney failure qualify for both Medicaid and Medicare. This is called being double eligible. If you’re dually eligible, Medicaid can help pay Medicare costs and provide extra coverage for services not fully covered by Medicare, such as long-term care.

Other health insurance programs include:

How much does health insurance cost?

The cost of health insurance can vary greatly depending on the type of plan you have, where you live and how much health care you need. When choosing a plan, it’s important to think about what you’ll pay each month and what you might have to pay when you get care.

There are a few key words that can help you understand how much your plan might cost. Knowing these terms can help you choose the plan that’s right for you.

• Premium: Your premium is the amount you pay, usually monthly, to your insurance company to have health insurance. It’s like a membership fee.
• Out-of-pocket costs: These are the costs of medical treatment that you pay for, even if you have health insurance. This usually includes a fixed amount you pay for a covered service, such as a doctor’s visit, prescription, or lab work. After paying the fixed amount, your insurance covers the remaining cost.
• Copay: A fixed dollar amount you pay for a covered health care service, which could include a doctor’s visit, prescription or lab test.
• Deductible: The amount you have to pay yourself before your insurance starts paying out.
• Co-insurance: It is your share of the costs of a covered health service, calculated as a percentage. Once you’ve met your deductible, your insurance plan pays a percentage of the bill and you pay the rest.
• Benefits package: The set of health services and items that your health insurance plan covers. This includes things like doctor visits, hospital stays and medication. Each insurance plan has a different benefit package, so it is important to read the details to know what is included and what is not.
• Flexible Spending Account (FSA): A benefit offered by some employers that allows you to set aside money from your paycheck before tax is deducted. You can use this money to pay for health expenses such as copays and medications.
• Health Savings Account (HSA): You can use a special savings account to pay for certain medical expenses. You must have a high-deductible health plan (health insurance with lower monthly costs, but you pay more out-of-pocket before the insurance starts to help) to open an HSA. The money you deposit is not taxed and you can use it for things like doctor’s appointments and medicines.

Who can help you understand your insurance plan?

If you feel overwhelmed, there are people who can walk you through your options, answer questions and help you make informed choices.

• Service coordinators: These specialists at hospitals and clinics will help you understand what your insurance covers and can help with applications for financial assistance or secondary insurance.
• Social workers: Social workers at hospitals and clinics can explain insurance options and connect you with support programs like Medicare, Medicaid, and disability benefits.
• Human Resources (HR): HR staff at your workplace can explain your job-based plan, help with enrollment and answer questions about what’s covered and how to make changes.
• Representatives of insurance companies: You can call your insurance provider for help understanding your benefits, in-network providers, pre-authorization or billing questions.
• Market Navigators: These trained professionals offer free help applying for plans in the Marketplace and understanding your health coverage.

Does health insurance cover CKD?

Most health insurance schemes generally cover diagnosis and management of chronic kidney disease (CKD)because there are protections in place for people with pre-existing conditions (health problems you had before you started a new health insurance plan).

Private insurance companies usually cover:

• Office visit to a primary care physician or nephrologist
• Routine blood and urine tests
• Medicines
• Access to network specialists (doctors or healthcare professionals) who have an agreement with your health insurance plan to provide services for a certain price.

Each plan is different, so it’s important to check your plan’s Summary of Benefits to see what kidney-related care is covered. Check your insurance company’s website, your employer’s HR department or the state-run Health Insurance Marketplace to learn how to access your summary of benefits, depending on what kind of insurance you have.

Medicare

This public health insurance program helps cover health care for people who are 65 or older, those living with certain disabilities or kidney failure. If you have kidney failure, Medicare helps cover the services and treatments you need to manage your condition. This includes dialysis (in hospital, outpatient or at home), kidney transplantshome dialysis training and related supplies and medications.

Medicare is divided into four parts. Each part covers specific types of care:

• Part A (hospital insurance): Helps cover 24-hour treatment in hospitals, tests, hospice and some home nursing care, including 24-hour dialysis and kidney transplant surgery
• Part B (Health insurance): Helps cover outpatient treatment such as doctor visits, laboratory tests, dialysis medical fees and anti-rejection drugs (immunosuppressants) after kidney transplantation
• Part C (Medicare Advantage): A private insurance plan bundled with Medicare that may offer additional benefits. Kidney failure coverage depends on the plan and where you live, so check carefully
• Part D (Prescription Coverage): Helps cover the cost of prescription drugs and home dialysis

Things Medicare does not cover:

• Paid helpers: People you pay to help you with daily tasks or medical care at home, such as setting up dialysis or helping you move around
• Lost income or caregiver’s salary during dialysis training
• Housing during dialysis treatment

Supplemental Medical Insurance (Medigap)

Since Medicare doesn’t cover everything, you can also buy Medigap from a private company to help pay for things like deductibles and copays that Medicare doesn’t fully cover.

Medicare eligibility timeline
Medicare eligibility depends on your age, health, and sometimes your work history. Here’s a simple look at when you might qualify for Medicare based on your health or age.

• Standard age-based eligibility
  • The first enrollment period starts three months before your 65th birthday
  • Ends three months after your birthday month
  • If you miss this 6-month period, you may still qualify for special enrollment if you meet certain requirements, such as losing employer insurance or moving
• Disability-based eligibility (under 65)
  • You are eligible if you receive social security disability insurance
  • You are eligible after 24 months of benefits
• Requirements for work history: Medicare Part A (hospital insurance) is typically free if you have worked and paid Medicare taxes for 10 years. If you have less work experience, you can still get Part A, but you will have to pay a monthly premium.
• Eligibility for renal failure: Even under age 65, you can get access to Medicare faster if you have kidney failure.
  • Dialysis
    • Standard waiting period: Medicare starts on the first day of the 4th month after starting center dialysis
    • If you are in a Medicare-certified home dialysis training program within first 3 months, coverage can start the first month of dialysis.
  • Kidney transplant
    • Medicare can begin:
      • During the transplant month, if the kidney transplant or the required hospital stay takes place that month or within 2 months
      • Up to 2 months before transplantation if you were hospitalized earlier

If you are over 65 and have Medicare coverage for kidney failure, it ends 12 months after you stop dialysis or 36 months after a successful kidney transplant. Your Medicare coverage resumes if you start dialysis again or have a kidney transplant within 12 months of stopping dialysis.

ACA plans

The ACA is helping more people get affordable health insurance. It created Marketplace for health insurance where you can buy and compare plans. All ACA plans must cover essential health services, including care for chronic conditions such as kidney disease. These plans are sold by private insurance companies, but they follow rules set by the government to protect you.

• Major Health Benefits: These are services that all ACA plans must cover, such as outpatient care, hospitalization, and prescription drugs.
• Annual or lifetime limits: ACA plans are not allowed to set annual or lifetime dollar limits for essential benefits, such as hospital visits or prescription drugs

Unlike Medicare, there is no specific enrollment period tied to age or a set timeline for applying for Medicaid. You can apply for Medicaid at any time of the year. Eligibility is based on need rather than age.