Understanding health insurance

What are the types of health insurance?

There are two main ways to get health insurance: through your job or through a government program. Plans generally fall into two main categories: private or public health insurance. Understanding the different types of health insurance can help you decide which options might be best for you and your family.

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 or older or who have certain disabilities or kidney failure, also 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 medicines.
• Medicaid: Medicaid is a government program that provides free or low-cost health coverage for people with limited income and resources. It 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 being dually eligible. If you're dually eligible, Medicaid can help pay Medicare costs and provide extra coverage for services not fully covered by Medicare, like long-term care.

Other health insurance programs include:

• TRICARE: Healthcare program for military families
• COBRA: This federal law may let you keep your health coverage from a former employer for a limited time after your job ends
• Veterans Health Administration (VHA) Programs: Health care for eligible veterans
• Children's Health Insurance Program (CHIP): CHIP provides low-cost health coverage to children and pregnant women in families that earn too much money to qualify for Medicaid but cannot afford private insurance
• Indian Health Service: The federal agency that provides health care to Native Americans and Alaska Natives

How much does health insurance cost?

The cost of health insurance can vary a lot 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 pay every month and what you might have to pay when you get care.

There are a few 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 to have health insurance. It's like a membership fee.
• Out-of-Pocket Costs: These are the expenses for medical care that you pay for, even if you have health insurance. This usually includes a fixed amount you pay for a covered service, like a doctor's appointment, prescription or lab work. After paying the fixed amount, your insurance covers the remaining cost.
• Copay: A set 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 starts to pay.
• Co-insurance: This is your share of the costs for a covered health service, calculated as a percentage. After 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 your health insurance plan covers. It includes things like doctor visits, hospital stays and medicine. Each insurance plan has a different benefits package, so it's important to read the details to know what's included and what's not.
• Flexible Spending Account (FSA): A benefit offered by some employers that lets you set aside money from your paycheck before taxes are taken out. You can use this money to pay for health care expenses like copays and medicines.
• Health Savings Account (HSA): A special savings account 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 insurance starts helping) to open an HSA. The money you put in is not taxed, and you can use it for things like doctor visits and medical supplies.

Who can help you understand your insurance plan?

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

• Benefits coordinators: These specialists at hospitals and clinics help you understand what your insurance covers and can assist with applications for financial help or secondary insurance.
• Social workers: Social workers at hospitals and clinics can explain insurance options and connect you to 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.
• Insurance company representatives: You can call your insurance provider to help understand your benefits, in-network providers, prior authorization or billing questions.
• Marketplace navigators: These trained professionals offer free help to apply for plans on the Marketplace and understand your health coverage.

Does health insurance cover CKD?

Most health insurance plans generally cover the 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 visits with a primary care doctor or nephrologist
• Routine blood and urine tests
• Medicines
• Access to in-network specialists (doctors or health care professionals) who have an agreement with your health insurance plan to provide services at a certain cost.

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 government-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 the hospital, outpatient or at home), kidney transplants, training for home dialysis and related supplies and medicine. 

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

• Part A (Hospital insurance): Helps cover inpatient care in hospitals, tests, hospice and some home health care, including inpatient dialysis and kidney transplant surgery
• Part B (Medical insurance): Helps cover outpatient care like doctor visits, lab tests, dialysis doctors' fees and anti-rejection medications (immunosuppressants) after kidney transplant
• Part C (Medicare Advantage): A private insurance plan bundled with Medicare that may offer extra benefits. Coverage for kidney failure depends on the plan and where you live, so check carefully
• Part D (Prescription coverage): Helps cover the cost of prescription medicines and in-home dialysis

Things Medicare does not cover: 

• Paid aides: People you pay to help you with daily tasks or medical care at home, like setting up dialysis or helping you move around
• Lost income or caregiver pay during dialysis training
• Housing during dialysis treatment 

Medical Supplement 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
  • Initial enrollment period starts three months before your 65th birthday month
  • Ends three months after your birthday month
  • If you miss this 6-month period, you still may qualify for special enrollment if you meet certain requirements, such as losing employer insurance or moving
• Disability-based eligibility (under age 65)
  • You qualify if you're receiving Social Security disability insurance
  • You qualify after 24 months of benefits
• Work history requirements: Medicare Part A (hospital insurance) is typically free if you've worked and paid Medicare taxes for 10 years. If you have less work experience, you can still get Part A, but you'll need to pay a monthly premium.
• Kidney failure eligibility: Even under age 65, you can access Medicare sooner if you are in kidney failure.
  • Dialysis
    • Standard wait: Medicare starts on the first day of the 4th month after beginning in-center dialysis
    • If you're in a Medicare-certified home dialysis training program within the first 3 months, coverage can start the first month of dialysis.
  • Kidney transplant
    • Medicare can begin:
      • 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 earlier

If you are over 65 and have Medicare coverage for kidney failure, it will end 12 months after you stop dialysis or 36 months after a successful kidney transplant. Your Medicare coverage will resume if you start dialysis again or get a kidney transplant within 12 months after you stopped getting dialysis.

ACA Plans 

The ACA helps more people get affordable health insurance. It created the Health Insurance Marketplace where you can shop for 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 all ACA plans must cover, such as outpatient care, hospitalization and prescription medicine.
• Yearly or lifetime limits: ACA plans are not allowed to set yearly or lifetime dollar limits on essential benefits, like hospital visits or prescription medicine

Unlike Medicare, there isn't a 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 instead of age.

Does health insurance cover dialysis and transplants?

Health insurance generally covers dialysis and kidney transplants, though the specific coverage details and out-of-pocket costs will depend on your insurance plan.

Most employer-sponsored/private insurance plans cover:

• In-center or home dialysis
• Surgery and hospital stay for transplant
• Anti-rejection medicines (usually under prescription drug coverage)

You may need to use a specific dialysis or transplant center within your plan's network. Check your plan or speak with a benefits coordinator who can help you understand your options and avoid unexpected costs.

Medicare 

Medicare covers kidney transplants if the surgery is done at a Medicare-approved hospital. Part A covers your hospital stay, the full care of your living kidney donor, lab work and other hospital services. Part B and D cover doctor visits, blood work and immunosuppressants (medicines that help prevent your body from rejecting the kidney). 

Medicaid 

Most state Medicaid programs cover:

• Dialysis (home and in-center)
• Transplant evaluation and surgery
• Follow-up care and medicines

Coverage varies depending on where you live, so be sure to check your state's Medicaid program. Learn more.

ACA plans 

• ACA plans must cover dialysis and transplants if they are necessary
• Dialysis is typically covered as outpatient or inpatient care
• Transplants are covered, but coverage for donor costs may vary
• Immunosuppressants are usually included in prescription benefits

Learn more about the cost of dialysis

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

No. Whether you get insurance through your job or buy your own plan, health insurance companies cannot: 

• Deny you coverage because you have kidney disease or another pre-existing condition
• Charge you more because of your kidney condition
• Exclude kidney-related care, like dialysis or transplant coverage, from your plan 

It's important to review your insurance plan carefully. If you're getting insurance through a job, there may be a waiting period for new employees before coverage starts.  

Questions to ask your insurance company 

Knowing what to ask your insurance provider can empower you to make informed decisions and ensure you get the most from your coverage. You can usually find your insurance company's phone number on the back of your insurance card.

When you call, have your insurance card handy and consider asking these questions: 

• What is my deductible, copay, and co-insurance for doctor visits, specialist visits (like a nephrologist), lab tests, and prescription medicines?
• Does my plan cover kidney disease education services, and how many sessions are included?
• Do I need a referral from my primary care doctor to see a kidney specialist (nephrologist) or a dietitian?
• Are my current medicines, including any specific to CKD, covered? Are there any quantity limits or preferred pharmacies I must use?
• What are the coverage specifics for different dialysis modalities (in-center hemodialysis, home hemodialysis, peritoneal dialysis)? Are specific clinics or home dialysis providers in-network?
• If I eventually need a kidney transplant, what does my plan cover for the transplant evaluation, surgery, and post-transplant care, including immunosuppressants?
• What is my out-of-pocket maximum for the year?
• What happens if I receive care from an out-of-network provider or facility?
• How does my plan work with Medicare if I also have Medicare coverage?
• What is the process for appealing a denied claim or requesting coverage for a service or medicine not initially covered? 

Need financial assistance?

Please talk with your social worker about all available resources and options for financial assistance.