Medicare alone is not enough to cover medical costs for people living with kidney failure. A supplemental plan is needed to cover the 20 percent out-of-pocket costs that have no lifetime cap under Medicare. In about half the states, insurers are not required to offer Medigap insurance (which helps cover copayment, coinsurance and deductibles) to kidney failure patients under age 65. More than 92,000 dialysis patients under 65 live in these states. There are also many challenges facing ESRD patients on Medicaid, including difficulty accessing specialists and a lack of coverage of needed benefits in many states. There are no annual limits on Medicare out of pocket costs.