© 2015 Medicare Rights Center January 2015 Medicare Benefits, Options, and Transitions Rules for People with ESRD Audio Portion: 1-866-740-1260 Web Portion:

© 2015 Medicare Rights Center

January 2015

Medicare Benefits, Options, and Transitions Rules for People with

ESRD

Audio Portion: 1-866-740-1260Web Portion: www.ReadyTalk.com

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Let’s Learn Medicare

Medicare Benefits, Options, and Transitions Rules for People with ESRD

© 2015 Medicare Rights Center 7

Medicare Rights Center

The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through:Counseling and advocacyEducational programsPublic policy initiatives


National Council on Aging

This toolkit for State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs), and Aging and Disability Resource Centers (ADRCs) was made possible by grant funding from the National Council on Aging


This training will cover Parts of Medicare Medicare eligibility and enrollment for people with End-Stage

Renal Disease (ESRD) also known as kidney failure Medicare coverage and costs for ESRD treatment Other types of insurance and ESRD Medicare

The 30-month coordination period Coverage of immunosuppressant drugs after a kidney

transplant Medigap, Medicare Advantage plans, and Part D enrollment for

people with ESRD ESRD and the Health Insurance Marketplaces

Note: Eligibility, enrollment and coordination of benefits work differently for ESRD Medicare than for Medicare based on age or disability. However, Medicare covers medical care for ESRD the same way as it covers care for people with Medicare due to age or disability.


Parts of Medicare

Medicare benefits administered in three parts:Part A – Hospital/Inpatient BenefitsPart B – Doctors/Outpatient BenefitsPart D – Prescription Drug Benefit

What happened to Part C? Medicare Advantage Plans (e.g., HMO, PPO)Way to get Parts A, B, and D through one private planAdministered by a private insurance companyNot a separate benefit: everyone with Medicare

Advantage still has Medicare


Medicare Eligibility and Enrollment for ESRD

Patients


Medicare eligibility based on ESRD

Someone is eligible for Medicare if: The person has End-Stage Renal Disease

(ESRD), meaning that they have permanent kidney failure that requires dialysis or a kidney transplant; and

The person, their spouse, or their parent has enough Medicare work history to qualify for Social Security or Railroad Retirement benefits (RRB)


When Medicare begins with ESRD The date when someone’s Medicare benefits begin depends on

the type of treatment they receive

Dialysis at a facility Home dialysis Kidney transplant

• Medicare begins after a three-month waiting period while receiving dialysis• Coverage begins on the first day of the fourth month of dialysis• Waiting period starts even if someone does not choose to sign up for Medicare

• No waiting period• Medicare begins the same month as the home dialysis training program• A doctor must expect that the beneficiary can finish the training program and continue home dialysis after it ends

• No waiting period• Medicare begins the month someone goes into a Medicare-approved hospital for the transplant or the health care services needed before the transplant—as long as they get the transplant over the following two months

Author

make example in the notes section a slide in the presentation, maybe include a calendar chart of some sort. This stuff is confusing and seeing an example would be great.


Enrollment case examples

Dialysis at a facilityMs

Self dialysisM

Kidney transplantM


End of Medicare coverage for ESRD If an individual has Medicare only because of ESRD,

Medicare coverage will end:12 months after the month the individual stops dialysis

treatments

or36 months after the month of a successful kidney

transplant If they have Medicare based on ESRD and then enroll in

Medicare based on disability or age, Medicare enrollment continues

Note: If they had Medicare ESRD and it terminated, Medicare coverage will start again without a waiting period if they begin dialysis again or get another kidney transplant


Medicare eligibility for children with ESRD

Children can qualify for Medicare: must have ESRD and have at least one parent who has sufficient Medicare work history

Children are:People who are unmarried and age 21 and youngerPeople ages 22 to 25 in certain circumstances Adult dependent children


Medicare, ESRD, and age If an individual has Medicare based on age first, they

do not need ESRD Medicare unless:They need an earlier Medicare start date

ESRD Medicare can be retroactive up to one yearThey did not enroll in Part B during their Initial

Enrollment Period and want to enroll They get another IEP to enroll in ESRD Medicare Part B

without premium penaltiesThey already have Part B but pay a premium penalty

because they enrolled late Enrolling in ESRD Medicare Part B will remove the

premium penalty due to delayed Part B enrollment


Medicare, ESRD, and disability If an individual qualifies for Medicare based on

disability first, they may want to enroll in ESRD Medicare if:They are still within their 24-month waiting period for

Medicare based on disability ESRD Medicare will start earlier than their Medicare for

disability will They declined Part B during their Initial Enrollment

Period and want to enroll They get another IEP to enroll in ESRD Medicare Part B

without premium penalties


How to enroll in ESRD Medicare

Individual eligible for ESRD Medicare should enroll by calling Social Security (800-772-1213) or visiting local Social Security office

For incapacitated individual, a family member or other responsible party can also enroll for them

Eligible individual’s dialysis facility must complete and send a form to the Social Security Administration to confirm ESRD status and the type of treatment needed


Medicare coverage of ESRD treatment

Medicare covers: Kidney transplants Immunosuppressive drugs after a Medicare-covered kidney

transplantAs long as the person still qualifies for Medicare and has Part B

Hospital inpatient dialysis Outpatient dialysis from a Medicare-certified hospital or free-

standing dialysis facility Home dialysis training, equipment, supplies, and medications

from a dialysis facilityMedication is only covered when overseen by a physician

Note: Medicare covers all ESRD treatments the same way, regardless of whether someone has ESRD Medicare or Medicare due to age or disability.


ESRD Medicare costs

Medicare Part A Costs for 2015

Premium • Free for those with 10 years of Social Security work history• $224 if you or your spouse worked and paid Medicare taxes for 7.5 to 10 years• $407 if you or your spouse worked and paid Medicare taxes for fewer than 7.5 years

Hospital deductible

$1,260 for each benefit period

Hospital copay • $315 per day for days 61-90 each benefit period• $630 per day for days 91-150 (these are 60 non-renewable lifetime reserve days)

Skilled nursing facility copay

$157 per day for days 21-100 each benefit period

Original Medicare costs apply for people with ESRD Medicare:


ESRD Medicare costs

Note: coinsurance is sometimes called cost sharing

Medicare Part B Costs for 2015

Annual deductible $147

Monthly premium $104.90 per monthPeople with high incomes pay more for the monthly premium

Coinsurance Medicare pays 80% of Medicare-approved amount for a doctor’s service; you pay 20% coinsurance

Original Medicare costs apply for people with ESRD Medicare:


Medicare and other types of insurance for people with

ESRD


What to consider before enrolling in Medicare

How employer coverage coordinates with ESRD Medicare

How Medicare covers immunosuppressive drugs after someone has a kidney transplant


Employer insurance and Medicare For people with ESRD Medicare, employer insurance can

be any combination of: Active employer coverage from beneficiary or their spouseRetiree insuranceUnion coverageCOBRA

Employer coverage is primary to Medicare for the first 30 months a person qualifies for Medicare based on ESRDThe 30-month coordination period

Note: Coordination of benefits works differently for ESRD Medicare than for Medicare based on age or disability, but Medicare covers medical care for ESRD the same way as it covers care for people with Medicare due to age or disability.


The 30-month coordination periodDuring 30-month coordination

period

• Coordination period begins the month someone becomes eligible for Medicare• Employer insurance pays primary to Medicare during this time• Individual does not have to enroll in Medicare if they have other coverage

You have until the end of the 30- month coordination period to enroll in Medicare

After 30-month coordination period

• Medicare becomes primary payer• Must be actively enrolled in Medicare• This change will occur automatically, even if the individual never actively enrolled into Medicare


Employer insurance and ESRD Medicare If individual is enrolled in ESRD Medicare, it is the

secondary payer during the 30-month coordination periodThis means that employer insurance pays first and Medicare

pays second This is true for both insurance based on current

employment and retiree insurance The 30-month coordination period starts when they first

qualify to receive ESRD Medicare, even if they have not signed up for it yet

After the 30-month coordination period, ESRD Medicare pays primary to employer coverageThis switch is automatic and happens even if someone

never actively enrolls in ESRD Medicare


Taking Medicare for those with employer coverage If an individual has employer coverage, it may still be best to

enroll in ESRD Medicare when they first qualifyMost cost effective way to get careESRD patients need a lot of medical careEven if employer coverage is primary to ESRD Medicare, the

individual may still have deductibles, copays, and coinsurances Medicare will pay second and could help pay these costs Medicare will also place limits on the amount providers can charge

If they need an organ transplant and have Medicare when they get the transplant, Part B will cover their immunosuppressant drugs

People should talk to their employer before deciding to delay ESRD Medicare coverageAsk how costs will compare if they have employer coverage

alone versus employer coverage and Medicare


Delaying Medicare for people with employer coverage

If a person decides to delay ESRD Medicare enrollment:Delay enrollment in both Part A and Part BThis means they should not enroll in Part A and should

decline Part B If they defer enrollment in both Parts A and B, they can

enroll in both parts at any time while they still have ESRD If they enroll in Part A and decline Part B, they may have

gaps in coverage and higher costsThey will only be allowed to enroll in Part B during the

General Enrollment Period (GEP) (January 1 – March 31 of each year)

Premium penalty will apply for each 12-month period they delayed enrollment


Delaying Medicare for people with employer coverage

To prevent a gap in coverage, individual should apply for ESRD Medicare Parts A and B a few months before 30-month coordination period ends Ask for Medicare to begin the month after their coordination

period ends. Remember: 30-month coordination period begins the month a person

becomes eligible for Medicare After 30-month coordination period, Medicare pays first and

employer insurance pays second Once Medicare becomes primary, employer coverage can

refuse to cover someone if they failed to enroll in Medicare If individual had kidney transplant, they should enroll in

Medicare within one year of their transplant to make sure Medicare will cover immunosuppressive drugs


Medigaps, Medicare Advantage, and Part D for

people with ESRD


Medigap policies for people with ESRD

Medigap policies (Medigaps, also known as Medicare supplemental insurance): sold by private insurance companies, used to pay the costs associated with Original Medicare

Many people with Original Medicare purchase a Medigap to help pay Parts A and B cost-sharing

Federal law does not require Medigap insurers to sell Medigaps to people with ESRD who are under age 65States may have additional protections that allow

someone with ESRD to purchase a Medigap policy


ESRD and Medicare Advantage plans Most people with ESRD cannot join a Medicare

Advantage plan. Two exceptions:If individual has ESRD, can join a Special Needs Plan (SNP)

that specifically accepts people with ESRD, if there is one in their area SNP: type of MA plan that specifically serves members who have a

particular need, such as a chronic illnessIf individual has employer health plan coverage through the

same insurance company that offers a MA plan, can enroll in that company’s MA plan

If ESRD develops after individual joins a MA plan, plan cannot disenroll themIf the plan leaves Medicare, individual has one-time Special

Enrollment Period (SEP) to join another plan in their area


Enrolling in a Part D plan with ESRD Individuals with ESRD Medicare can enroll in a Part D plan

as they would with any other type of Medicare eligibility People with employer coverage should talk to their employers

to see how Medicare Part D would coordinate Many people with employer coverage may not need Part D

They can delay Part D without penalty if they have creditable coverage and join a Part D plan within 63 days of losing that coverage

Before joining a Part D plan, beneficiaries should make sure it will not cause their employer coverage to end for them or their family

If they do not have employer coverage, they should take Medicare Part D to help cover all their drug costs


Part D coverage of ESRD-related drugs A Part D plan must cover individual’s immunosuppressant

drugs if they do not qualify for Part B coverage for them All Part D formularies must include most all

immunosuppressive drugs Step therapy not allowed once individual is stabilized on

immunosuppressant drugHowever, prior authorization can apply to verify that Part B

won’t cover needed drugs even after individual is stabilized on them

Individuals should double check to make sure the drugs they need are covered with the fewest restrictions and that their plan includes their pharmacy as a preferred network pharmacy


ESRD and low-income programs Individuals with ESRD Medicare can qualify for low-

income programs to help with Medicare costs, such as:Medicare Savings Programs (MSP)Extra HelpMedicaid

If an individual qualifies, Medicaid can provide secondary coverage to MedicareIf individual has Medicaid and then develops ESRD, they

will likely have to enroll in Medicare Contact local Department of Social Services or State

Health Insurance Assistance Program (SHIP) for more information regarding these programs


Medicare Coverage of Immunosuppressant Drugs


Medicare coverage of immunosuppressants After an individual has a kidney transplant, they will need to take

immunosuppressant drugs for the rest of their lives to prevent body from rejecting organ

Normally, immunosuppressants are covered under Part A at the time of a Medicare-covered transplant

For post-discharge patient, Part B covers immunosuppressive drugs if: Individual had Part A at the time of their transplant, and Individual continues to have Part B

If they qualify for Medicare on the basis of ESRD alone, Medicare will end 36 months after a successful transplant

Medicare will not cover drugs after coverage ends If they qualify for Medicare on another basis (age or disability),

Medicare will not end and will continue to cover their immunosuppressive drugs


Medicare coverage of immunosuppressants

If individual did not have Medicare when they had a transplant, there are two ways to get coverage: Enroll retroactively in Part A if it is within a year of

their transplantGet coverage under their Part D plan since they do

not qualify for Part B coverage of their drugs


ESRD and the Health Insurance Marketplaces


Health Insurance MarketplacesA way for people to shop for health insurance

coverage

Also called Exchange or Insurance Exchange

Insurance purchased through the Marketplace = Qualified Health Plan (QHP)QHPs purchased through the Small Business Health

Options Program (SHOP) = SHOP plans

QHPs purchased by individuals through the Marketplace = QHPs

Marketplace operations vary by state


ESRD and the Marketplaces SHOP plans work with ESRD Medicare the same way

that other employer coverage does Anyone who has any part of Medicare already cannot

purchase a QHP Most people with Medicare are not eligible for tax credits

to purchase QHPs People with ESRD are eligible for tax credits if they have

not yet enrolled in any part of Medicare People with ESRD who have QHPs first can keep those

plans after they’ve taken MedicareCan still qualify for premium tax credits if they are under age 65

People with ESRD can choose to not enroll into Medicare and take a QHP instead


ESRD and the Marketplaces What form(s) of insurance to choose depends on many

factors:Medical costsExisting insurance (i.e. employer insurance)Coverage needs

If someone decides to forego ESRD Medicare and enroll in QHP, it is best practice to get written confirmation from the QHP that it will provide primary coverage

People with ESRD who are considering a QHP instead of or in addition to Medicare should do an analysis of QHP costs and coverage against their own needs

When someone with ESRD turns 65 or becomes eligible for Medicare due to a disability, they should enroll in Medicare

© 2015 Medicare Rights Center44

For more information and help Local State Health Insurance

Assistance Program (SHIP)www.shiptacenter.org www.eldercare.gov

Social Security Administration800-772-1213 www.ssa.gov

Medicare800-MEDICARE (633-4227)www.medicare.gov

Medicare Rights Center800-333-4114www.medicareinteractive.org

National Council on Agingwww.ncoa.org www.centerforbenefits.orgwww.mymedicarematters.org www.benefitscheckup.org

http://www.shiptacenter.org/

http://www.eldercare.gov/

http://www.ssa.gov/

http://www.medicare.gov/

http://www.medicareinteractive.org/

http://www.ncoa.org/

http://www.centerforbenefits.org/

http://www.mymedicarematters.org/

http://www.benefitscheckup.org/


Medicare Interactive Medicare Interactive

www.medicareinteractive.org Web-based compendium developed by Medicare

Rights to be used as a counseling tool to help people with MedicareEasy to navigateClear, simple languageAnswers to Medicare questions and questions about related

topics, for example:“How do I choose between a Medicare private health plan

(HMO, PPO or PFFS) and Original Medicare?”1.5 million annual visits and growing

45

http://www.medicareinteractive.org/

Documents

© 2015 Medicare Rights Center January 2015 Medicare Benefits, Options, and Transitions Rules for People with ESRD Audio Portion: 1-866-740-1260 Web Portion: