Medicare is an insurance program funded by the federal government and is available to those who are citizens or permanent residents of the United States and meet one of the following:

• >65 years old OR

• Are disabled (Medicare usually begins two years after disability) OR

• Have permanent kidney failure requiring dialysis or kidney transplant (end-stage renal disease, ESRD).

Medicare has two components, Part A and Part B

Medicare Part A Hospital Insurance- Offered free to those who qualify:

• Inpatient hospital services.

• Skilled nursing.

• Some home health services.

• Kidney, kidney-pancreas, and pancreas-after-kidney transplants.

• Certain heart, lung, liver, heart-lung, pancreas, and intestinal transplant, if you already have Medicare due to age or disability.

• Hospice care.

Medicare Part B Medical Insurance- Pay a Premium:

• Physician services.

• Outpatient hospital services.

• Medical equipment and supplies.

• Some other medical services part A doesn’t cover.

• Part of the cost of anti0rejection medications for the life of your transplanted organ, if your transplant was covered by Medicare and you are older than 65 or you are disabled according to Medicare for reasons other than ESRD.

Medicare Part D- Prescription Drug Coverage

Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. If you decide not to get Medicare drug coverage when you're first eligible, you will pay a late enrollment penalty of 1% of the premium payment for each month you do not enroll. For example, if you are eligible and wait a year, you will pay a premium that is 12% higher than if you enroll at the time of eligibility.

To get Medicare drug coverage, you must join a Medicare plan that offers prescription drug coverage. Each plan can vary in cost and drugs covered.

To find a Medicare drug plan that will work for you, please visit this site.

In general, the plans have monthly premiums and co-pay amounts that you will have to pay. Once your prescription costs reach a certain amount, there will be a period of time known as the ‘donut hole’ where you will need to pay 100% of your prescriptions covered by Medicare Part D.

Once you reach your out-of-pocket maximum, you will have ‘catastrophic coverage’ where medications will be covered at 95%. The premium co-pay and out-of-pocket amounts change each year. You will need to be prepared to cover out-of-pocket expenses under Medicare Part D. It is recommended that you apply for extra help to avoid the ‘donut hole.’

Visit this site to apply for the extra help program.

In terms of transplant medications and coverage, here is a table to explain medication coverage:

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“Medigap” Supplemental Policy or Secondary Insurance

You may choose to buy a private insurance policy to cover the portion of medical expenses that Medicare does not cover, since Medicare alone is not sufficient to cover 100% of transplant costs.

Medicaid is a state medical assistance program that covers most costs for hospital stays, clinic visits, and medication. There are some procedures or exams not covered by Medicaid, and some must be pre-approved. Some Medicaid programs are based on family income, and others are based on medical needs.

Medicaid is a state funded program and is based on need. There are two categories of need determined individually by each state:

• Categorically needy: if you fall below the income and resource level designated as the “poverty line” by your State.

• Medically needy (spend down): The “spend down” is the process of deducting medical costs from your income until your income level and you become eligible for Medicaid (not in all States).

Some individuals are exempt from the income-based rules, including those whose eligibility are based on blindness or disability, but eligibility requirements vary based on state. Visit your state’s Medicaid website for individual eligibility requirements or contact your financial coordinator at your transplant center for more information.

TRICARE is the federal government’s health insurance program for the branches of uniformed service. Patients must receive pre-authorization for transplant just like other forms of insurance. Contact your nearest branch for more information regarding your benefits and eligibility.

If your medical condition prevents you from working, you may qualify for disability benefits.

Social Security provides benefits to people who are disabled. Under this program:

• You must be unable to perform any work for which you are qualified.

• Your disability must be expected to last at least a year or result in death.

• You must have earned enough work credits when you were able to work (SSDI only).

• You must file a formal application.

• If you are turned down the first time but believe you qualify, you may file an appeal.

If you qualify,

• You may receive benefits until you are able to work again on a regular basis.

• Certain members of your family may also qualify for benefits.

• A number of incentives are available to help you return to work.

Social Security Administration disability programs

Social Security Disability Insurance (SSDI): SSDI is for individuals who are working and paying Social Security taxes. You must wait 5 months after disability begins to receive SSDI benefits. You may begin receiving these benefits while you are involved in an approved rehabilitation program.

Supplemental Security Income (SSI): SSI makes monthly payments to disabled individuals with few assets and low incomes. No waiting period is required before receiving SSI benefits.

Apply for disabilityas soon as you become disabled as the claims process can take 3-5 months to complete.

Review of your application: The Social Security office will check your application to see if you meet initial requirements for disability. They will then send your application to your State’s Disability Determination Service for a formal evaluation. Reviewers will gather information from your doctors about your medical condition, history and treatment, as well as your ability to perform normal work activities. You will receive written notice about your claim.

Even if another insurer or government agency has ruled that you are disabled, you must still meet Social Security requirements in order to receive Social Security benefits.

Review periods and termination of benefits: Your case will be reviewed periodically to see if you are still disabled. Your benefits will end if:

• You work on a regular basis and earn a certain amount of money per month after deducting disability-related work expenses.

• Your medical condition improves and you are no longer considered disabled (unless you are in a vocational rehabilitation program, like ticket to work, to learn more visit this site).

A family member may be able to take time off from work under the Family Medical Leave Act, and you and your family may be able to use Family Medical Leave Act benefits to protect your job while you are recovering. The Family Medical Leave Act (FMLA) of 1993 allows eligible employees to take up to 12 weeks of unpaid, job-protected leave for certain family and medical reasons. Not all companies are required by law to offer these benefits.

To be eligible for FMLA, an employee must:

• Work for a covered employer,

• Have worked for a total of 12 months, and

• Have worked at least 1,250 hours during the last 12 months.

FMLA benefits can be used to:

• Care for a spouse, child or parent with a serious health condition,

• Take medical leave when the employee can’t work due to a serious health condition, or

• Take blocks of time or work fewer hours daily or weekly.

Under the FMLA, the employer must:

• Inform employees of their rights and responsibilities under the FMLA,

• Continue insurance coverage while employees are on leave, and

• In most cases, return the employee to the same job or a job with equal pay and benefits.

Employees:

• May have to pay insurance premiums while on leave or

• May have to pay insurance premiums for the time off if they did not return to work after the FMLA time off.

You can get additional information about the Family Medical Leave Act by visiting this site.