Understanding health insurance

What are the types of health insurance?

Health insurance in the U.S. is divided into public and private health insurance. With public health insurance, some or all of the costs are paid for by the government. With private health insurance, you pay for it yourself or the costs are split between you and your employer.

What are the types of public health insurance?

The U.S. has two main public health insurance programs:

• Medicare, a federal program that covers people older than age 65 and people with disabilities, including nine out of 10 Americans with kidney failure

• Medicaid, a state-based program which covers low-income adults and children who qualify 

What are the types of private health insurance?

There are different types of private health insurance in the U.S. These are also sometimes called commercial insurance plans. Here are some of the most common ones:

• Health insurance through your job. Your employer pays for part of the cost, while you pay the rest as a monthly bill (premium). You may also get health insurance through your spouse's employer or under your parent's plan if you are under the age of 26.

• Individual health coverage. Coverage you buy and pay for yourself. The most common way to do this is through the health insurance marketplace at HealthCare.gov, the website created as part of the Affordable Care Act (also known as "Obamacare").

Other health insurance programs

There are other programs you may qualify for, such as:

• TRICARE: A health care plan that covers members of the U.S. military and other uniformed services and their families. 
• COBRA: A federal law that allows you to keep your health plan if you get insurance through your job and become unemployed or lose your employer-sponsored coverage for other reasons.

What are the costs for health insurance?

The amount you have to pay for health insurance varies based on your coverage. If you qualify for public insurance, you usually pay less than if you have private insurance. You may have some or all of these costs:

• Premium: A set amount you pay each month, whether or not you use health care services. If you get health insurance through your job, your employer pays part of your premium.
• Out-of-pocket costs: Costs you pay for health care services, such as:
  • Copay: A set amount you pay each time you get a health care service
  • Deductible: A certain amount you pay before insurance will pay for the cost of health service.
  • Co-insurance: A percent of the cost of health services you have to pay after you meet your deductible.

What does having kidney disease mean for my health insurance coverage?

If you have kidney disease, you may wonder how it affects your options for getting and keeping health insurance. Here are answers to some common questions:

Can I be denied health insurance coverage because I have kidney disease?

No. The Affordable Care Act, a law that was passed in 2010, states that insurance providers cannot deny coverage to people with pre-existing conditions (a health condition you already have when signing up for a health insurance plan).

If you get health insurance through your job, your employer has to offer you the same coverage as other employees who work the same amount of hours. However, there may be a waiting period before new employees can get coverage for pre-existing conditions, so if you sign up for a new health insurance plan through your job, review coverage information carefully.

Do all health insurance programs cover treatments for kidney disease?

Under the Affordable Care Act, all health insurance plans have to cover certain essential health benefits, such as: 

• Emergency care
• Hospital stays
• Prescription medicines
• Services to manage chronic conditions, such as kidney disease

If you have kidney failure (also called end-stage renal disease), you qualify for Medicare even if you are under age 65. Medicare will cover most of the costs for dialysis, a kidney transplant or other treatments.

How can I find out which treatments my plan covers?

To know exactly which kidney disease treatments your health insurance plan covers, look at your plan's summary of benefits and coverage (SBC). This summary includes:

• How much you will have to pay out of pocket for certain treatments
• Which treatments are covered or are not covered by your plan

• Which medicines are covered

If you still have questions, contact your insurance provider — they are there to help you.

Is there a yearly or lifetime limit on how much health insurance will pay for treating kidney disease?

No. The Affordable Care Act states that insurance companies cannot set yearly or lifetime limits on how much they will pay for essential benefits covered by your plan.