When people are sick, it is important that they have access to quality medical care. When they have a chronic illness, it is essential to their wellbeing. While most people with end-stage renal disease (ESRD, or kidney failure) are eligible for Medicare after 90 days, many have other insurance that they wish to use as their primary payer, and many more need to purchase Medigap plans to cover what Medicare does not. Like anyone else, it is a choice that they should have. Low-income ESRD patients who cannot afford the cost of their insurance premiums may apply for assistance through the American Kidney Fund’s Health Insurance Premium Program (HIPP). Recently insurers have begun rejecting third-party payments made on behalf of patients by AKF, and some have gone so far as to deny coverage to patients who need charitable assistance to pay their premiums. We believe that the discussion about how low-income ESRD patients are being excluded from participating in commercial insurance products should be fully informed. We believe that there are four corners to this issue – the patient; the program; the protections; and the practices of insurers related to patients whose care is expensive. 


Why putting the patient at the center of the discussion is essential

  • Health insurance is the gateway to medical care, critical for people with ESRD who will die without ongoing dialysis treatment or a transplant.
  • ESRD patients not only need access to dialysis, but they typically suffer from other conditions that require medical attention such as hypertension, diabetes and cardiovascular challenges, as well as many complications of kidney failure.
  • Medicare alone covers only 80 percent of the expenses associated with dialysis, leaving the patient liable for the balance. Medigap is essential, and close to 50 percent of our HIPP grants are for Medigap, but Medigap is not available in every state to ESRD patients younger than 65.
  • Meanwhile, the physical and time demands of dialysis mean that patients often cannot work—the vast majority of our grantees find it difficult to continue working while on dialysis and 70 percent have been forced to stop working because of their disease.
  • Poverty is a byproduct of this condition—60 percent of the patients we help have annual incomes under $20,000 while facing out-of-pocket costs each year of $7,000 after paying premiums.
  • The ultimate therapeutic benefit many dialysis patients hope and strive for is a kidney transplant, but the fact is that the patients who have insurance are much more likely to receive a kidney transplant.
  • The reality is, many people will have to spend years on dialysis while waiting for a transplant.
  • Many will never be able to have a transplant for health reasons or the shortage of available organs.
  • Our assistance allows patients to access complete health care services offered under their plan, including transplant workups and transplants.
  • There are currently 79,000 dialysis patients in the U.S. who rely on the HIPP program for insurance support. 
  • We help people with all types of health insurance: Medicare Part B, Medigap, commercial, COBRA, and employer group health.
  • It is important to note that not only does ESRD have an enormous financial impact on patients generally, but also disproportionately impacts certain populations that have been historically underserved.  For example, African-Americans and Hispanics are at a higher risk for the conditions that cause ESRD, and are disproportionally affected by the limits of access to health insurance. Over half of the people who receive help under our program are people of color.

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How the HIPP program works

  • AKF has been helping patients with the payment of insurance premiums for nearly two decades, and was established 45 years ago to help one patient pay for dialysis treatment.
  • There are multiple hallmarks of HIPP that are in place for the purpose of ensuring the integrity and objectivity of the program:
    • Using donor funding, we provide help to patients solely on the basis of their financial need. We carefully review each applicant’s financial status and require that they meet specific income to expense criteria in order to qualify for our help.
    • Donor funding is provided to AKF without any restrictions or conditions whatsoever—funds go into one funding pool and from that pool we administer the program providing grants to eligible low-income dialysis patients to pay for their insurance premiums.
    • Help is provided without regard to the type of insurance they have, where they live, or whether their dialysis provider is a donor to our program. Many dialysis providers with patients being assisted by our program do not contribute to AKF.
    • In fact, our patient grant department does not have access to information about which providers have contributed to AKF.
    • Our independent Board of Trustees includes a subcommittee with responsibility for oversight of HIPP and the membership of that committee excludes anyone associated with a dialysis center, including employees, officers, shareholders or owners of such centers.  AKF employees are further prohibited from being shareholders or otherwise affiliated with dialysis companies.
    • Patients chose their coverage with no input from AKF—we are not involved in helping patients find new insurance and do not provide patients with advice on which insurance plan to choose.
  • Patients may change their health insurance coverage—and their provider—at any time, and AKF will continue to help them.

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We have rigorous, need-based standards for selecting recipients to receive premium assistance. These standards have been reviewed and approved by the federal government

  • AKF has always taken a comprehensive approach to ensuring the integrity of our work with ESRD patients, and HIPP was established according to our own high standards and those approved by the federal government:
    • To ensure integrity by a charity providing third-party payments for health insurance, the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) has approved standards to guard against abuses or violations of law.
    • The HHS OIG-approved standards bar specific practices which might steer patients into particular plans or to particular health care providers.
    • We asked the HHS OIG to examine AKF’s administration of the HIPP program, and after review, the OIG issued an advisory opinion, 97-1, approving AKF’s program
    • The OIG also cited AKF’s program in a subsequent bulletin as the example of how such a program can work
  • The nation’s leading charity watchdog organizations—including Charity Navigator, Consumer Reports, CharityWatch and the Better Business Bureau Wise Giving Alliance—have recognized AKF as one of the nation’s most trusted and respected charities.

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Insurer actions and patient interests

  • We are strongly advocating at the federal and state levels against discriminatory practices on the part of insurance carriers.
  • As a business matter, insurers have sought to keep expensive patients with chronic illnesses off of their insurance rolls by disallowing patients who had pre-existing conditions or by placing lifetime caps on coverage for people who had costly illnesses such as cancer, HIV/AIDS and ESRD;
  • Courts have found lifetime caps on specific diseases to be discriminatory and the Affordable Care Act does not allow companies to exclude people with pre-existing conditions from being insured.
  • Now insurers are turning to other strategies to limit their financial exposure related to lifesaving care provided to low-income patients by refusing third-party payments on behalf of patients even though such payments are explicitly allowed by the federal government. 
  • In Louisiana in 2014, insurers embarked on a failed effort to restrict third-party payments of insurance premiums on behalf of people with HIV/AIDS.
  • Now insurers have undertaken numerous efforts to restrict insurance from ESRD patients, including bringing a lawsuit and lobbying state insurance officials to restrict third-party payments for premiums.
  • Some health insurers are implementing policies that say individuals may not receive any support from a charitable organization that might increase their ability to pay for their insurance.
  • Some plans have gone so far as to simply refuse to insure people who need charitable help to afford their expenses. These carriers make applicants sign an attestation that they are not receiving such help, and are announcing that accepting charitable assistance is grounds for coverage termination.
  • A primary tenet of the Affordable Care Act is to provide insurance coverage for all, regardless of their medical condition.  We believe that this pattern of actions on the part of insurers to purge their insurance rolls of medically vulnerable populations violates the guaranteed availability provisions of the ACA. This practice should be stopped so that dialysis patients in need can obtain insurance coverage of their choosing.
  • For more than two years, we have been fighting at the state and federal levels against this growing industry practice. We will continue to stand up for the rights of low-income people who need charitable assistance to afford their health care.

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