Chronic kidney disease (CKD) refers to all five stages of kidney disease, from very mild damage in CKD stage 1 to kidney failure in CKD stage 5. The stages of kidney disease are based on how well the kidneys are working to filter waste and extra fluid out of the blood. In the early stages of kidney disease, your kidneys are still able to filter out waste from the blood. In the later stages, your kidneys cannot adequately clear waste products and maintain fluid balance, so renal replacement treatments such as renal transplant and dialysis may be needed.1
People with CKD have a variety of insurance coverage options available to them. While there may be limitations, it’s helpful to know your options and how they impact you.
Employer group health plans (EGHPs) are insurance plans that a person has through either their own employer or the employer of their spouse, parent or domestic partner. These plans are offered through employers and may administered by common health insurance carriers such as Humana, Anthem Blue Cross And Blue Shield (BCBS), Cigna and other well-known carriers. Plan types include Preferred Provider Organizations (PPOs), in which a subscriber has access to a larger number of in-network providers, and Health Maintenance Organizations (HMOs), which carry more restrictions and require subscribers to visit only specific providers.
EGHPs have in-network and out-of-network benefits. A subscriber who receives care from an out-of-network provider may incur more out-of-pocket cost than if he or she had visited an in-network provider. Most plans provide a list of in- and out-of-network providers to their members and most EGHPs cover renal transplant expenses, including the immunosuppressive drugs required post-transplant.2
Medicare is an insurance option available to people beginning at age 65 years or people with certain disabilities before age 65 subject to certain other eligibility requirements.3 The diagnosis of end stage renal disease (ESRD) qualifies a person for Medicare enrollment regardless of age.
Medicare has four parts—A, B, C and D. Part A is hospital insurance, which covers hospitalizations, in-patient care in a skilled nursing facility, hospice and home healthcare services. Medicare Part B provides coverage for the cost of dialysis, including dialysis supplies, and physician and other healthcare provider services. Combined Medicare Parts A and B provide coverage for organ transplant services and immunosuppressive drugs. Medicare Part B includes an annual deductible and monthly premium and only covers 80% of billed charges—including charges for dialysis services—so additional insurance is needed for full coverage of healthcare costs.4
Medicare Part C plans, known as Advantage plans, are administrated through health insurance carriers such as Humana, Anthem and Cigna. These plans come with additional benefits that are not part of traditional Medicare A and B, such as dental and vision care. Like traditional Medicare B, there is a monthly premium and a deductible associated with Medicare Advantage plans. ESRD patients who have not enrolled in a Medicare Advantage plan prior to their ESRD diagnosis are currently not eligible to choose Medical Advantage plans, but that will change in 2021, when ESRD patients will be eligible to enroll in a Medicare Advantage plan.5
Medicare Part D is the prescription coverage portion of Medicare. Administrated through a health insurance carrier, these plans—like Parts B and C—have a monthly premium. These plans are offered through health insurers such as UnitedHealth, AARP, BCBS, Anthem and others. AARP is a common provider of Part D plans, which are chosen through Medicare. When choosing the right plan for you, base the decision on your current medications and frequency of use. Medicare provides a tool to find a plan that may fit patients’ needs.
While Medicare is a federally funded program, state-funded insurance programs such as Medicaid and Managed Medicaid Plans are also available. These income- and asset-based plans typically require an annual application to assess eligibility to receive state insurance. Managed Medicaid Plans (MCOs) are becoming more common to help states manage healthcare needs. These plans are administrated through commercial healthcare insurance carriers that contract with the state. MCOs may include additional services not provided by traditional Medicaid.
A person who is not currently working or works for a small employer that does not offer insurance, is not eligible for Medicare or does not disqualify for state Medicaid programs, may be able to enroll in federal exchange or Affordable Care Act (ACA) plans. There is a lot of state–to-state variability, so a person may enroll either through his or her state or the health insurance marketplace. Income-based subsidies may be available to offset the monthly premium cost for exchange or ACA plans.6
Many healthcare insurance options are available. Talking to someone at your physician’s office may help determine the best insurance choice for you.
American Kidney Fund. Stages of Chronic Kidney Disease. http://www.kidneyfund.org/kidney-disease/chronic-kidney-disease-ckd/stages-of-chronic-kidney-disease/. Accessed April 18, 2019.
U.S. Department of Health and Human Services. Medicare Coverage of Kidney Dialysis & Kidney Transplant Services. https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf. Accessed April 18, 2019.
Life Options Rehabilitation Program. 2003. Employment: A Kidney Patient’s Guide to Working & Paying for Treatment. https://lifeoptions.org/assets/pdfs/employment.pdf.
1 American Kidney Fund. Stages of Chronic Kidney Disease. http://www.kidneyfund.org/kidney-disease/chronic-kidney-disease-ckd/stages-of-chronic-kidney-disease/. Accessed April 18, 2019.
2 Life Options Rehabilitation Program. 2003. Employment: A Kidney Patient’s Guide to Working & Paying for Treatment. https://lifeoptions.org/assets/pdfs/employment.pdf.
3 U.S. Department of Health and Human Services. Medicare Coverage of Kidney Dialysis & Kidney Transplant Services. https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf, at p. 6. Accessed April 18, 2019.
4 U.S. Department of Health and Human Services. Medicare Coverage of Kidney Dialysis & Kidney Transplant Services. https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf. Accessed April 18, 2019.
5 Kirchhoff, SM. 2018. Medicare Coverage of End Stage Renal Disease (ESRD). Report for Congress, Congressional Research Service. https://fas.org/sgp/crs/misc/R45290.pdf.
6 U.S. Centers for Medicare & Medicaid. www.healthcare.gov. Accessed April 18, 2019.