Let’s Learn Medicare Medicare for People with End-Stage Renal Disease (ESRD)

Let’s Learn Medicare

Medicare for People with End-Stage Renal Disease (ESRD)

© 2015 Medicare Rights Center 2

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 Medicare eligibility and enrollment for people with End-Stage

Renal Disease (ESRD) Medicare coverage of ESRD treatment Other types of insurance and ESRD Medicare

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

transplant Medigaps, Medicare Advantage plans, and Part D enrollment

for people with ESRD ESRD and the Health Insurance Marketplaces

Note: If you have ESRD Medicare, enrollment and coordination of benefits rules are different than the rules for age- or disability-related Medicare. ESRD Medicare covers ESRD treatments as well as any other medically necessary treatment.


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 People with

ESRD


Medicare eligibility based on ESRD

You are eligible for Medicare if: You have End-Stage Renal Disease (ESRD)

Permanent kidney failure that requires dialysis or a kidney transplant

You, your spouse, or your parent has enough Medicare work history to qualify for Social Security benefits

Note: you do not have to be 65 years old to qualify for ESRD Medicare


When Medicare begins with ESRD Medicare benefits begin depending on how you receive your

ESRD treatment:

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 you do not sign up for Medicare

• No waiting period• Medicare begins the same month as the home dialysis training program• You must be able to finish the training program and continue home dialysis after it ends

• No waiting period• Medicare begins the month you go into a Medicare-approved hospital for transplant or the services needed before transplant—as long as you get transplant over the following two months


End of Medicare coverage for ESRD If you have Medicare only because of ESRD, Medicare

coverage ends:12 months after the month you stop dialysis treatments

or36 months after the month of a successful kidney

transplant If you have ESRD Medicare and then enroll in Medicare

based on age or disability, your Medicare coverage will continue

Note: If you had ESRD Medicare and it ended, Medicare coverage starts again without a waiting period if you begin dialysis again or get another kidney transplant


How to enroll in ESRD Medicare If you are eligible for ESRD Medicare, call Social

Security (800-772-1213) or visit your local Social Security office to enroll

A family member or other responsible party can also enroll for you if you are unable to do so

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 Immunosuppressant drugs after a Medicare-covered

kidney transplantAs long as you still qualify for Medicare and has Part B

Inpatient and outpatient dialysis Home dialysis training, equipment, supplies, and

medicationsMedication is only covered when overseen by a physician

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


Medicare and Other Types of Insurance for People with

ESRD


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

be any combination of: Active employer coverage from you or your spouseRetiree insuranceUnion coverageCOBRA

Employer coverage is primary to ESRD Medicare only for the first 30 months that you qualify for ESRD MedicareThis is called the 30-month coordination period

Remember: 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 you become eligible for Medicare• Your employer insurance pays primary to Medicare during this time• You do not have to enroll in Medicare if you have other coverage

After 30-month coordination period

• Medicare becomes your primary payer• This change happens automatically; after 30-month coordination period ends, Medicare automatically becomes your primary insurance

• This is why it is important to enroll in Medicare before the 30-month coordination period ends

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


Taking ESRD Medicare

If you have employer coverage, it may still be best to enroll in ESRD Medicare when you first qualify to help pay costs associated with careRemember, if you have enrolled in Medicare, it pays

second during the 30-month coordination period

Talk to your employer before taking or delaying ESRD MedicareAsk how costs will compare if you have employer

coverage alone versus employer coverage and Medicare


Delaying ESRD Medicare

If you delay ESRD Medicare enrollment:Delay both Part A and Part B

If you delay both Parts A and B, you can enroll in both at any time while you still have ESRD

If you enroll in Part A and decline Part B, you may have gaps in coverage and higher costs

Only allowed to enroll in Part B during certain times of year

Premium penalty applies for each 12-month period of delayed enrollment

To prevent gaps in coverage, apply for ESRD Medicare Parts A and B at least a few months before your 30-month coordination period ends


Medigaps, Medicare Advantage, and Part D for

People with ESRD


Medigap policies for people with ESRD Medigap policies (Medigaps) pay the cost-sharing

associated with Original Medicare If you have ESRD Medicare, you may not be able to

purchase a Medigap 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 policyContact your State Health Insurance Assistance

Program (SHIP) or Area Agency on Aging (AAA) for more information

To find your SHIP or AAA, call 877-839-2675


ESRD and Medicare Advantage plansMost people with ESRD cannot join a Medicare

Advantage plan There are some exceptions to this ruleTo find out the exceptions, contact your State Health

Insurance Assistance Program (SHIP) or Area Agency on Aging (AAA)

To find your SHIP or AAA, call 877-839-2675 If you develop ESRD after joining a Medicare

Advantage plan, the plan cannot disenroll you


Enrolling in a Part D plan with ESRD If you have ESRD Medicare, enroll in Part D as you

would with any other type of Medicare eligibility Talk to your employer to see how Medicare Part D would

coordinate with your coverage People with employer coverage may not need Part D

You can delay Part D without penalty if you have creditable coverage and join a Part D plan within 63 days of losing coverage

Before joining a Part D plan, make sure it will not cause employer coverage to end

If you do not have employer coverage, enroll in Medicare Part D to help cover drug costs


ESRD and low-income programs

If you have ESRD Medicare, you can qualify for low-income programs to help with Medicare costs, such as:Medicare Savings Programs (MSPs)Extra HelpMedicaid

Contact your State Health Insurance Assistance Program (SHIP) or Area Agency on Aging (AAA) for more information on programs that can help you afford Medicare costsTo find your SHIP or AAA, call 877-839-2675


Medicare Coverage of Immunosuppressant Drugs


Medicare coverage of immunosuppressants After a kidney transplant, you will need to take

immunosuppressant drugs for the rest of your life to prevent your body from rejecting the new kidney

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

After you leave the hospital, Part B covers immunosuppressant drugs if you had Part A at the time of the transplant, so long as you continue to have Part B

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

transplant; orGet coverage under your Part D plan if you do not qualify for

Part B coverage of your drugs


Part D coverage of ESRD-related drugsPart D plans must cover your immunosuppressant

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

immunosuppressant drugsCheck to make sure your drugs are covered with

the fewest restrictions and that your plan includes your pharmacy as a preferred network pharmacy


ESRD and the Health Insurance Marketplaces


Health Insurance MarketplacesPart of the Affordable Care Act (ACA)

Also known as ObamacareA 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 plansQHPs purchased by individuals through the

Marketplace = QHPs


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

that other employer coverage doesMust follow the 30-month coordination period

If you have any part of Medicare already, you cannot purchase a QHP for individuals

Two groups of people with ESRD may want to consider an individual QHP instead of or in addition to Medicare (assuming not already enrolled in Medicare, in which case a QHP is not allowed): You have a QHP when you develop ESRDYou are uninsured and have ESRD

You should compare the costs and coverage of these options before making a decision


ESRD and the Marketplaces When comparing costs, consider:

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

If you decide to forego ESRD Medicare and enroll in a QHP, get written confirmation from your QHP that it will provide primary coverage

If you are considering a QHP instead of or in addition to Medicare, compare QHP costs and coverage against your own needs

When you turn 65 or become eligible for Medicare due to a disability, you should enroll in Medicare

© 2015 Medicare Rights Center29

For more information and help Local State Health Insurance

Assistance Program (SHIP)www.shiptacenter.org 877-839-2675

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.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/

© 2015 Medicare Rights Center

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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

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Let’s Learn Medicare Medicare for People with End-Stage Renal Disease (ESRD)

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