Common Insurance Health Care Plans

To understand all of your healthcare insurance benefits and the different plans that may be available to you, you need to know what your options are. Here are six of the most common insurance plans.

To understand all of your health care insurance benefits and the different plans that may be available to you, you need to know what your options are. Here are some of the most common insurance plans.

Employer Group Health Plan (EGHP)

Medical insurance provided by your employer (or through your spouse’s or partner’s employer) is called an employer group health plan (EGHP). If you’re retired and receive medical benefits from your former employer as part of your pension plan, this is also considered an EGHP. Many EGHPs will cover all or some of your doctor, hospital, dialysis and prescription costs, leaving you responsible for paying only the deductible, coinsurance or copay. It is likely that your employer will pay a portion of the premium, and you will see the remainder of the cost as a deduction from your paycheck. Coverage varies based on the plan.

COBRA

If you are at risk for losing your insurance coverage because of job loss, reduced hours or another life event, such as divorce or death of a spouse/domestic partner, you may be able to extend your existing insurance coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA is the same health insurance you have through your EGHP, but your premium costs may increase when you elect COBRA because your employer is no longer paying part of the premium. There’s also a limit to how long you can maintain COBRA coverage, which varies by plan.

Individual Coverage

If you do not have access to or do not wish to be covered by an available EGHP, Individual Coverage may be an option. There are two primary ways to buy Individual Coverage—which is available as both an individual plan, covering just you, or as a family plan:

1. Via health insurance marketplaces created by the Affordable Care Act:

  • These health insurance marketplaces, or exchanges, provide a variety of options from several insurance plans that you can select based on your specific needs. Depending on your income and other factors, you may also be eligible for cost sharing reduction and premium tax credits that can reduce or eliminate the cost to you.
  • You must a citizen or legal resident to enroll in a health insurance marketplace plan.
  • If you are enrolled in Medicare, you are not eligible to enroll in a marketplace plan.
  • Important note: If you enroll in a health insurance marketplace plan and later enroll in Medicare, Medicare will become your primary insurance carrier. You should keep this in mind if you are considering Medicare enrollment.

2. Via health insurance carriers directly:

  • Many health insurance carriers will sell coverage directly to you.
  • Although you may not have the same options to choose from that you would on the health insurance marketplace, going directly to a health insurance carrier to buy individual coverage may be a good option if you do not qualify for health marketplace subsidies, if you do not have documentation or legal residency, or if you are already enrolled in Medicaid but would prefer to enroll in commercial coverage as your primary coverage and maintain Medicaid as secondary.

Medicare

Medicare isn’t specific to people who are 65 or older. It’s also for people of any age with end stage renal disease (ESRD) who need a transplant or dialysis and meet the following requirements:

  • You are a U.S. citizen or legal resident, and:
    • Paid the required amount in Social Security and Medicare taxes through your job, or
  • Are the spouse or dependent of someone who qualifies for Medicare because they have paid the required amount into Social Security

Medicare is run by the Social Security Administration. You will need to sign up by phone or email—enrollment is not automatic. There are four parts of Medicare that cover different services:

1. Part A: Medicare Part A is hospital insurance. If you need to be admitted into a hospital, Medicare Part A will cover some of those costs. Medicare Part A will also help cover the costs of a skilled nursing facility and hospice care as well as some health care services.

2. Part B: Medicare Part B pays for doctor appointments, outpatient dialysis and other services that Part A does not cover. Also, Medicare Part B charges a premium based on your income level. If you stop paying your premium, your Part B coverage will terminate and will not assist you with costs for outpatient services.

Transplant benefits

  • Medicare Part B covers transplant and immunosuppressive drugs for 36 months after transplant, at which point Medicare coverage ends unless you are entitled to Medicare for a different entitlement reason (such as age) at that point in time.
  • For DaVita patients, discuss with your insurance counselor the financial implications of your health insurance choice prior to receiving your transplant. All post-transplant questions (including insurance-related) should be referred to your transplant team.

3. Part C (sometimes referred to as Medicare Advantage): A Medicare Advantage (MA) plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Most MA plans also offer prescription drug coverage. These plans typically require you to pay a fixed copay for treatment. In order to join an MA plan, you must meet one of the following criteria in addition to being eligible for Medicare:

  • You were already enrolled in an MA plan prior to being diagnosed with ESRD.
  • You have an employer plan through a company that offers MA plans.
  • You’ve had a successful kidney transplant.

4. Part D: Medicare Part D is prescription drug coverage available to people on Medicare. If you elect this coverage, you pay a yearly deductible, a monthly premium and copayments for your drugs. Patients on Medicare Part D plans can experience an annual coverage gap that limits what the plan will cover for prescribed drugs. The annual coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. There can be prescriptions that are not covered by Medicare.

Late enrollment penalty for Part B

 If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you are enrolled in Medicare. Your Part B premium may increase up to 10 percent for each 12-month period you were eligible for Part B, but were not enrolled.

 NOTE:

1. If you are eligible for Medicare based on ESRD and not age, you can enroll in Medicare at any time without having a late enrollment penalty.

2. If you enroll in Medicare Part A, but not in Medicare Part B, regardless of age, you will incur a late enrollment penalty upon enrolling in Medicare Part B.

3. If you are eligible for Medicare based on age, you will incur a penalty if you delay enrollment in Medicare Part B.

4. If you are paying a late enrollment penalty because you didn’t enroll in Medicare Part B when you were first eligible, the penalty will stop when you become eligible for Medicare based on ESRD.

Medigap/Medicare Supplement

You may also be eligible for a Medigap/Medicare Supplement plan to help cover any remaining services. In most cases, you will have a premium to pay for these plans and a window of time for application. If you apply during this initial application timeframe, you can buy any Medigap policy that is available in your state.

Medicaid

Medicaid is a joint federal and state program. The eligibility criteria and plan coverage are state-specific, and typically based on financial and/or medical need. Medicaid benefits will cover only services rendered by providers who accept Medicaid and typically will not cover services outside your state.

Some Medicaid programs will cover additional services such as dental, transportation and prescription benefits. As stated above, covered benefits and eligibility vary by state. Ask your insurance counselor for more details on the eligibility and benefit requirements by your state.

Children’s Health Insurance Program (CHIP)

CHIP provides low-cost health coverage to children for families that do not qualify for Medicaid or private insurance. In some states, CHIP also covers pregnant women.

Each state offers CHIP coverage and works closely with its state Medicaid program. You can apply any time. If you qualify, your coverage can begin immediately, any time of year.

Other government coverage

Active and inactive military personnel and their families may be eligible for benefits offered by TRICARE of the Department of Veterans Affairs (VA). Coverage levels vary and should be verified for each medical service you need.

Everyone’s insurance plan and health needs are unique. If you would like to discuss your coverage options or have questions, please reach out to one of these resources:

  • Patients with chronic kidney disease (CKD) who have not yet started dialysis, please call the Patient Advocate Helpline 1-888-405-8915.
  • Dialysis patients with end stage renal disease (ESRD), please contact your insurance counselor or social worker OR fill out our Insurance Support Form.

More information about Insurance & Financial Management Support

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