Common Insurance Plans 

  Common Insurance Plan

To understand all of your insurance benefits and the different options that may be available to you, you need to know what insurance plan you have. Common insurance plans include:

  • Employer Group Health Plan (EGHP)
  • COBRA
  • Medicare
  • Medigap
  • Medicaid
  • Veteran’s Benefits

Employer Group Health Plan (EGHP)

Medical insurance provided by your employer at work is called Employer Group Health Plan or EGHP. If you are retired and receive medical benefits from your former employer as part of your retirement or pension plan, this is also considered an EGHP.

EGHP insurance often provides more complete benefits than state or federal programs.  Premiums are generally more affordable since it is a group plan. Some employers even cover part of the cost for the insurance premiums. Understanding your benefits package is important. Contact your employer’s human resources department to find out more details.

EGHPs have different plan types, and oftentimes a patient’s choice is affiliated with the patient’s premium costs. 

Common EGHPs

  • Health Maintenance Organizations (HMOs):HMOs are managed through an organization that is responsible for providing comprehensive health services to its members. 
    • With this plan, you must have a primary care physician (PCP) and will need prior authorization before services can be offered.
    • Members also have a network of providers that they can choose from within the organization’s network area.
    • HMOs generally have a lower premium but more restrictions regarding patient choice
  • Preferred Provider Organization (PPOs): PPOs offer a network of preferred providers where members have a choice of utilizing in-network or out-of-network benefits. 
    • The plan requires no referral.
    • Members are subject to a deductible and share of cost until out of pocket maximums are met.
    • PPOs generally have a higher premium with more patient choices.

If you are experiencing life-changing events that could result in loss of your EGHP coverage, COBRA may be available for you. Before dropping any insurance coverage or if you intend on making any changes to your current insurance coverage, please speak with your DaVita social worker or insurance specialist. DaVita wants to make sure you have all the facts before making any changes.

COBRA

COBRA is an option to continue benefits through your employer’s health insurance even if you, or your spouse, are unable to keep working. If you lose your job through termination, are laid off, have reduced work hours or choose to quit working, you and your family qualify for COBRA insurance. COBRA is the same health insurance you have through your EGHP, but be aware that your premium costs will increase when you elect COBRA. Speak with your social worker or insurance specialist to review programs that can assist in paying for these costs.

If you are entitled to COBRA benefits, your employer’s health plan must give you notification of your rights to choose to continue your benefits. There are strict timelines that must be followed when electing your COBRA benefits. For additional information, read What Is COBRA?

Medicare

Medicare is a federal insurance program available to most people in the United States who are 65 or older, disabled or have kidney failure. 

It is important to know that:

  • There are two main parts to Medicare: Parts A and B. 
    • Part A covers in-patient care
    • Part B covers physician services, supplies and outpatient services, including dialysis
  • Medicare pays for only 80% of the allowed expenses for Parts A and B, so you will need additional insurance to cover the rest. (Medigap or Medicaid may be an option for you; see below.)

For additional information on Medicare, read Medicare and Chronic Kidney Disease.

Medigap

Medigap plans, also known as Medicare supplements, are sold by insurance companies to cover all or part of the 20% “gap” that Medicare does not cover. Each state has different plans to choose from, with varying benefits and cost. People who are at least 65 years old and apply in the first six months of obtaining Medicare cannot be denied or made to wait for coverage because of kidney disease. If you are under 65, some states may allow you to buy Medigap coverage. Contact your state’s Department of Insurance or call 1-800-MEDICARE to learn which plans are available and if you are eligible.

Medicaid

Medicaid is a state-funded medical assistance program that is based on financial need. You may qualify for Medicaid if you are 65 or older, are disabled, have dependent children, or have little income or savings. Programs vary from state to state and year to year.

Medicaid covers services such as hospital charges and doctor fees. Your state may also have a program to help people with kidney disease pay for dialysis, medications and transportation.  Speak with your social worker or state medical assistance office to determine what options are available to you.

Veteran benefits

The Department of Veterans Affairs (VA) may offer enrolled veterans a medical benefit package that can provide a full range of preventive outpatient and inpatient services within the VA healthcare system. Veterans have a choice of dialyzing in hospitals, rather than at dialysis facilities where the VA may not cover the full cost. The VA may also be able to provide assistance with your prescription drugs. To learn more about what benefits you may qualify for, contact 1-877-222-VETS (8387) or visit www.va.gov/healtheligibility.

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