public health insurance
These plans are funded by the government and help certain groups of people:
- State health insurance: Medicare is a federal health insurance program for people over age 65 or who have certain disabilities or kidney failureAlso called end-stage renal disease (ESRD) or end-stage renal disease (ESKD). There are different parts of Medicare that cover different types of care, including hospital stays and prescription drugs.
- Health insurance: Medicaid is a government program that provides free or low-cost health coverage for people with limited income and resources. Covers eligible adults, children, pregnant people, older adults and people with disabilities. Medicaid rules and benefits vary by state. Many people with kidney failure qualify for both Medicaid and Medicare. This is called having dual eligibility. If you are dual eligible, Medicaid can help pay for Medicare costs and provide additional coverage for services that Medicare does not fully cover, 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 medical care you need. When choosing a plan, it’s important to think about what you pay each month and what you might have to pay when you receive care.
There are some key terms 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 for health insurance. It’s like a membership fee.
- Out of pocket costs: These are health care expenses you pay, even if you have health insurance. This usually includes a fixed amount you pay for a covered service, such as a doctor’s appointment, prescription, or lab test. 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 must pay out of pocket before your insurance plan begins to pay.
- Coinsurance: This is your share of the costs for a covered health service, calculated as a percentage. Once you’ve met your deductible, your insurance plan will pay a percentage of the bill and you’ll pay the rest.
- Benefits package: The set of health care services and items covered by your health insurance plan. It includes things like doctor visits, hospital stays, and medications. Each insurance plan has a different benefits 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 taxes are deducted. You can use this money to pay for health care expenses, such as copays and medications.
- Health Savings Account (HSA): A special savings account that you can use to pay for certain medical costs. You must have a high-deductible health plan (health insurance with lower monthly costs, but you pay more yourself before the insurance starts to help) to open an HSA. The money you contribute is not taxable and you can use it for things like doctor visits and medical supplies.
Who can help you understand your insurance plan?
If you feel overwhelmed, there are people who can explain your options, answer questions, and help you make informed decisions.
- Benefits Coordinators: These hospital and clinic specialists help you understand what your insurance covers and can assist you 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): Human resources staff at your workplace can explain your work-based plan, help you with enrollment, and answer questions about what’s covered and how to make changes.
- Representatives of insurance companies.: You can call your insurance provider to understand your benefits, in-network providers, prior authorization, or billing questions.
- Market Navigators: These trained professionals offer free help applying for plans on the Marketplace and understanding your health coverage.
Does health insurance cover CKD?
Most health insurance plans generally cover the diagnosis and treatment of chronic kidney disease (CKD)because there are protections for people with pre-existing conditions (health problems you had before starting a new health insurance plan).
Private insurance companies generally covers:
- Office visits to a primary care doctor or nephrologist.
- Routine blood and urine tests.
- Medications
- Access to specialists within the network (doctors or health care professionals) who have an agreement with your health insurance plan to provide services at a certain cost.
Every 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 human resources department, or the government-run Health Insurance Marketplace to find out how to access your benefits summary depending on the type of insurance you have.
State health insurance
This public health insurance program helps cover health care for people over 65, 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 transplantstraining for home dialysis and related supplies and medications.
Medicare is divided into four parts. Each part covers specific types of care:
- Part A (Hospital Insurance): Helps cover hospital care, tests, palliative care, and some home health care, including dialysis and kidney transplant surgery
- Part B (Medical Insurance): Helps cover outpatient care such as doctor visits, lab tests, dialysis medical fees and anti-rejection medications (immunosuppressants) after kidney transplant
- Part C (Medicare Advantage): A private insurance plan included with Medicare that may offer additional benefits. Coverage for kidney failure depends on the plan and where you live, so check carefully
- Part D (prescription drug coverage): Helps cover the cost of prescription medications. and home dialysis
Things Medicare does No cover:
- Paid assistants: People you pay to help you with daily tasks or home health care, such as preparing for dialysis or helping you move around.
- Loss of income or caregiver payment 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 Schedule
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 initial enrollment period begins three months before the month of your 65th birthday.
- It 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.
- Eligibility based on disability (under 65 years of age)
- You qualify if you receive Social Security disability insurance
- You qualify after 24 months of benefits
- Work history requirements: Medicare Part A (hospital insurance) is usually 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.
- Kidney Failure Eligibility: Even before age 65, you can access Medicare sooner if you have kidney failure.
- Dialysis
- Standard wait: Medicare begins on the first day of the fourth month after you start in-center dialysis.
- If you are in a Medicare-certified home dialysis training program within the first 3 months, coverage may begin the first month of dialysis.
- Kidney transplant
- Medicare can start:
- During the month of the transplant, if the kidney transplant or necessary hospital stay occurs that month or within 2 months
- Up to 2 months before transplant, if you were hospitalized before
- Medicare can start:
- Dialysis
If you are over 65 and have Medicare coverage for kidney failure, it will end 12 months after stopping dialysis or 36 months after a successful kidney transplant. Your Medicare coverage will resume if you start dialysis again or receive a kidney transplant within 12 months of stopping dialysis.
ACA Plans
The ACA helps more people get affordable health insurance. created the Health insurance market where you can buy and compare plans. All ACA plans must cover important health services, including care for chronic conditions like kidney disease. These plans are sold by private insurance companies, but they follow rules set by the government to protect you.
- Essential 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 cannot set annual or lifetime dollar limits on essential benefits, such as hospital visits or prescription medications.
Unlike Medicare, there is no specific enrollment period tied to age or set timeline for applying for Medicaid. You can apply for Medicaid at any time of the year. Eligibility is based on need and not age.
