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How the Affordable Care Act affects Dialysis Patients

You may have heard about the Affordable Care Act, but more likely you’ve heard it called “Obamacare”. Whatever you call it, it is the law of the land and requires everyone, adults and their children, to have health insurance or pay a penalty. But the law isn’t just about requiring people to buy insurance; it’s about making health insurance cover the services people most need and keep them from financial ruin in the face of an unexpected medical event. In that way it’s not unlike the Medicare ESRD benefit that was enacted in 1972 that allowed more people with kidney failure an affordable way to receive dialysis treatments and kidney transplants. Prior to the Medicare benefit most people with kidney failure died because there was limited access to dialysis and transplantation. Most Americans with kidney failure are enrolled in Medicare today, regardless of their age, and will not need to purchase health insurance in the Marketplace.

However as a dialysis patient you may still have many questions about the Affordable Care Act and how it may or may not help you and your family. Here’s what you really need to know about the Affordable Care Act if you are a dialysis patient.

Q. If I have Medicare do I have to buy health insurance in the Marketplace?

A. No, there is no need for you to purchase additional health insurance through the Marketplace if you are covered by Medicare. In addition, it is illegal for an insurer to try and sell you a health insurance plan through the Marketplace if you already have Medicare. There is also no reason for you to obtain a health insurance plan in the Marketplace as it is unlikely to offer you additional benefits above what Medicare covers.

Q. I have Medicare, but I do not have any supplemental coverage. Can I buy supplemental coverage in the Marketplace?

A. No, unfortunately Marketplace plans are primary health insurance and will likely not pay the 20% coinsurance on medical treatments.

Q. I am losing my supplemental coverage because of the Affordable Care Act, what do I do now?

A. In some states patients with ESRD who are under 65 were able to purchase secondary coverage through the Pre-existing Condition Insurance Program established by the Affordable Care Act in 2010. Most states were planning to end their programs January 1, 2014, but the Federal Government recently committed to provide funding to help support states’ existing programs through March 2014. In addition, the Centers for Medicare & Medicaid Services (CMS) recently reported that they will permit insurers to sell supplemental policies on the individual insurance market to Medicare beneficiaries under age 65 through December 31, 2015. CMS expects this will give states enough time to find a permanent solution for those who are losing their supplemental coverage.

Q. I have Medicare, but my spouse and my children are uninsured. Will I have to pay a penalty if they don’t get health insurance? Can we get financial assistance to help pay for insurance for them?

A. Yes, if your family members do not have health insurance you will pay a penalty on your 2014 income taxes. That penalty for 2014 is $95 per adult $47.50 per child or 1% of household income (whichever is larger) and increases in following years. The good news is now there are more affordable options for your family members through the Health Insurance Marketplace and if your family makes between 100-400% of the poverty level, financial assistance is available to reduce the cost of premiums. They also may be eligible for the state Medicaid and State Children’s Health Insurance Program.

Q. I am on the transplant list. Will the Affordable Care Act help me when my Medicare ends 36 months after transplant?

A. Yes, if you are under age 65 and receive a kidney transplant your Medicare coverage will expire after 36 months (unless you have Medicare due to a disability other than ESRD). When that coverage expires you will be eligible to get insurance through your employer without any waiting period or restrictions due to a pre-existing condition. If you are not employed or your employer doesn’t offer health insurance, you will be eligible to purchase coverage in the Marketplace and receive financial assistance to do so if you meet the income requirements and are legally in the U.S.

Q. I don’t qualify for Medicare. Can I get coverage in the Marketplace?

A. If you are in the U.S. legally, but have not earned enough credits to qualify for Medicare you will be able to purchase coverage in the Marketplace and may qualify for tax credits and subsidies if you meet income requirements and have proper documentation of your legal status.

Q. How does the Affordable Care Act help me pay for my prescription medications?
If you have Medicare Part D the coverage gap also known as the donut hole is being phased out over the next 6 years so that you have to pay less out-of-pocket for your medications when you reach the coverage gap threshold. In 2014, you pay 50% of the costs of your brand name drugs and 79% of your generic drug costs when you reach the donut hole, but by 2020 the donut hole will be closed and you will pay 25% of your drugs (brand and generic).

In sum, if you have Medicare don’t enroll in the Marketplace. The Affordable Care Act does not change your Medicare except that it helps you pay for your prescription medications by closing the Medicare Part D donut hole.