Federal & State Insurance
There are a number of governmental programs that may be able help you pay for your kidney care:
In certain circumstances, (layoffs, reduced hours) you may be able to continue your insurance through COBRA (Consolidated Omnibus Budget Reconciliation Act). COBRA covers certain former employees and their eligible family members on their Employee Group Health Plan for a certain amount of time. To use COBRA, you must pay the full premium—which means your share and your employer’s share—for 18 months. You also may be charged a 2% administrative fee.
Some companies are so small that they are not required to provide COBRA. In this case, your state may have a similar plan. Check with your state insurance department (look for the map at http://www.naic.org) to see if your state offers this.
If you have been diagnosed with End Stage Renal Disease (ESRD), you are entitled to receive Medicare, regardless of your age or level of disability.
Medicare is a federal health plan for people who meet one of the following criteria:
- Are at least 65 years old
- Have been on Social Security Disability Insurance (SSDI) for 24 months
- Have chronic kidney failure that requires dialysis or transplant. Medicare due to kidney failure pays for any Medicare services, not just kidney care.
Medicare has 4 parts:
- Part A (Hospital Insurance)
- Part B (Medical Insurance)
- Part C (Medicare Advantage)
- Part D (Prescription Drug Coverage)
If you get Medicare Part A, you can also get Part B; enrolling in Part B is your choice. You may need both Part A and B in order for Medicare to cover some dialysis and kidney transplant services. With Original Medicare (Part A, or Part A and B), you can go to any doctor in the U.S. who sees Medicare patients.
When to Sign Up for Medicare
If you don’t have Medicare, you can sign up for it when you start dialysis:
- If you choose In-Center Hemodialysis, Medicare will start to pay on the first day of your third full month of treatment. So, if you start treatment on January 20, Medicare would first pay as of April 1.
- If you choose home dialysis, Medicare will start to pay in your first month of treatment.
Medicare as a secondary payer
It can save you money to have an EGHP and Medicare. When you have both, Medicare can help pay for deductibles, co-pays, or coinsurance your EGHP doesn’t pay. Of course, this only works if the service is one that Medicare covers. Having Medicare also means that providers who take Medicare must agree to accept Medicare’s allowed charge. If your EGHP pays at least this much, you will owe nothing.
To learn more, contact Medicare at 1-800-MEDICARE or online at www.medicare.gov.
Medicare Advantage plans are health plans offered by private companies under contract to Medicare. They are also called Medicare + Choice plans, or "Part C." You may enroll in a Medicare Advantage plan instead of the Original Medicare plan if you live in the plan's service area. If you join a Medicare Advantage plan, you are still in the Medicare program and have Medicare rights and protections. You will get complete Medicare Part A and Part B coverage, and many Medicare Advantage plans offer prescription drug coverage through the plan.
If you have low income and few assets, your state Medicaid plan might help you pay your health care bills. Medicaid covers some inpatient and outpatient healthcare costs, and can help pay for some things Medicare doesn’t, like routine transportation to dialysis. Federal law requires states to cover some services, but others are optional. Ask your social worker or contact your state Medicaid office to find out what your state covers.
Some states may have programs that enable people to get Medicaid benefits if they are disabled and work. Medicaid always pays last if you have Medicare and/or other health coverage. Check with your social worker or Medicaid office to see what programs are available in your state. You can apply for Medicaid at your state medical assistance office. Click here for a list of Medicaid offices by region.
Medicaid Risk (Managed Care Program)
If you are eligible, you may be required to join a managed care plan. When you join a managed care program, you will choose a personal doctor who will be responsible for making sure all your health care needs are met. The doctor will send you to someone else if you need more help than the doctor can provide.
Please check with your local social services department to see if you have to join a plan.
Medicare does not pay for all services. Even services that are covered may have a gap. A Medigap plan may help you pay Medicare deductibles and coinsurance. By Federal law, companies must sell Medigap plans to people in the first 6 months they have Medicare, if they are 65 or older. There is no waiting period—even if you have a health problem. Some states require companies to sell Medigap plans to people under age 65, and/or to people who lose their coverage. For a Medicare booklet on how to find and choose a Medigap plan, visit http://www.medicare.gov/Publications/Pubs/pdf/02110.pdf.
Active duty, retired or military dependents have one of four levels of TRICARE:
- The basic level is TRICARE Standard. With this plan, you may have co-pays and may have to file your own forms.
- Military and dependents can take TRICARE Prime. This is managed care; a primary case manager directs your care. Care providers will file claims for you. Plus, if you use TRICARE Prime providers, you’ll get TRICARE Extra, which saves you 5%.
- TRICARE for Life is a Medicare supplement for retirees and spouses, widows/widowers, or unremarried spouses.
- TRICARE Remote is for service members and dependents who live and work 50 or more miles from a military treatment facility.
See http://www.tricare.osd.mil/ to learn more about TRICARE.
Veterans who served in active duty may qualify for VA health benefits. You may pay less for services if you served in combat or have a service-connected disability. The VA benefit package includes:
- Preventive care
- Outpatient care
- Inpatient (hospital) care
- Medical supplies.
When you use the VA for medications, you’ll have a co-pay for prescribed and over-the-counter medications on their list of covered medications. Only a VA doctor can write a prescription for medications through the VA, so you must go to a clinic and see a VA doctor. There is a cap on how much any veteran must pay for medications each year. To learn more, see http://www.va.gov/healtheligibility.
If you can’t get TRICARE, you may be able to get CHAMPVA, a health plan for family members of veterans. You must be a spouse, surviving spouse or dependent child of a permanently and totally disabled veteran. This person must be still living or have died:
- While permanently and totally disabled
- Due to the disability
- In the line of duty
This program is run by the VA (Veteran’s Administration). To learn more, see http://www.va.gov/hac/forbeneficiaries/champva/champva.asp.
Indian Health Service
The Indian Health Service (IHS) provides:
- Inpatient care (requires hospitalization)
- Outpatient care (no hospital stay required)
- Chronic disease management programs for people with such diseases as diabetes and kidney disease
In most cases, you must belong to a federally recognized tribe living on or near a reservation to get IHS services. Some people who live in urban areas can get IHS services, too. The IHS provides care directly or through contracts with dialysis facilities and other healthcare providers. To learn more, visit http://www.ihs.gov/medicalprograms/kidney/
State High Risk Insurance Pools
At least 31 states have high-risk health insurance pools. These plans often provide short-term help to people who can’t get insurance due to poor health. Some limit coverage to those who can’t get Medicare. High-risk insurance may cost more than a group plan and may have fewer benefits. You can read more about which states have high-risk insurance pools, at: http://www.healthinsurance.org/riskpoolinfo.html.
State Kidney Programs
Your state may have funds to help pay your costs of care through a State Kidney Program. Your social worker can tell you if your state has one. Guidelines vary for who can get help and how much help the program can give you.