January 2015
Medicare Benefits, Options, and Transitions
Rules for People with ESRD
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© 2015 Medicare Rights Center
Let’s Learn Medicare
Medicare Benefits, Options, and
Transitions Rules for People with ESRD
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 advocacy
 Educational programs
 Public policy initiatives
© 2015 Medicare Rights Center
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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
© 2015 Medicare Rights Center
8
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.
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Parts of Medicare
 Medicare benefits administered in three parts:
 Part A – Hospital/Inpatient Benefits
 Part B – Doctors/Outpatient Benefits
 Part 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 plan
 Administered by a private insurance company
 Not a separate benefit: everyone with Medicare
Advantage still has Medicare
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Medicare Eligibility and
Enrollment for ESRD
Patients
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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)
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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 Medicareapproved 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
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Enrollment case examples
Dialysis at a facility
 Ms
Self dialysis
M
Kidney transplant
M
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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
or
 36 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
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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 younger
 People ages 22 to 25 in certain circumstances
 Adult dependent children
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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 year
 They 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 penalties
 They 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
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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
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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
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Medicare coverage of ESRD treatment
Medicare covers:
 Kidney transplants
 Immunosuppressive drugs after a Medicare-covered kidney
transplant
 As long as the person still qualifies for Medicare and has Part B
 Hospital inpatient dialysis
 Outpatient dialysis from a Medicare-certified hospital or freestanding dialysis facility
 Home dialysis training, equipment, supplies, and medications
from a dialysis facility
 Medication 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.
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ESRD Medicare costs
 Original Medicare costs apply for people with ESRD Medicare:
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
© 2015 Medicare Rights Center
ESRD Medicare costs
 Original Medicare costs apply for people with ESRD Medicare:
Medicare Part B Costs for 2015
Annual deductible
$147
Monthly premium
$104.90 per month
People 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
Note: coinsurance is sometimes called cost sharing
© 2015 Medicare Rights Center
Medicare and other types of
insurance for people with
ESRD
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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
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Employer insurance and Medicare
 For people with ESRD Medicare, employer insurance can
be any combination of:
 Active employer coverage from beneficiary or their spouse
 Retiree insurance
 Union coverage
 COBRA
 Employer coverage is primary to Medicare for the first 30
months a person qualifies for Medicare based on ESRD
 The 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.
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The 30-month coordination period
During 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
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
You have until the end of the 30- month
coordination period to enroll in Medicare
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Employer insurance and ESRD Medicare
 If individual is enrolled in ESRD Medicare, it is the
secondary payer during the 30-month coordination period
 This 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 coverage
 This switch is automatic and happens even if someone
never actively enrolls in ESRD Medicare
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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 qualify
 Most cost effective way to get care
 ESRD patients need a lot of medical care
 Even 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 coverage
 Ask how costs will compare if they have employer coverage
alone versus employer coverage and Medicare
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Delaying Medicare for people with employer coverage
 If a person decides to delay ESRD Medicare enrollment:
 Delay enrollment in both Part A and Part B
 This 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 costs
They 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

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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 30month 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
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Medigaps, Medicare
Advantage, and Part D for
people with ESRD
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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 65
 States may have additional protections that allow
someone with ESRD to purchase a Medigap policy
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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 illness
 If 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 them
 If the plan leaves Medicare, individual has one-time Special
Enrollment Period (SEP) to join another plan in their area
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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
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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 drug
 However, 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
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ESRD and low-income programs
 Individuals with ESRD Medicare can qualify for lowincome programs to help with Medicare costs, such as:
 Medicare Savings Programs (MSP)
 Extra Help
 Medicaid
 If an individual qualifies, Medicaid can provide secondary
coverage to Medicare
 If 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
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Medicare Coverage of
Immunosuppressant Drugs
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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
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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 transplant
 Get coverage under their Part D plan since they do
not qualify for Part B coverage of their drugs
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ESRD and the Health
Insurance Marketplaces
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Health Insurance Marketplaces
 A 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
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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 Medicare
 Can 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
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ESRD and the Marketplaces
 What form(s) of insurance to choose depends on many
factors:
 Medical costs
 Existing 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
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For more information and help
 Local State Health Insurance 
Assistance Program (SHIP)
 www.shiptacenter.org
 www.eldercare.gov
 Social Security Administration
 800-772-1213
 www.ssa.gov
 Medicare
 800-MEDICARE (633-4227)
 www.medicare.gov
 Medicare Rights Center
 800-333-4114
 www.medicareinteractive.org
National Council on Aging
 www.ncoa.org
 www.centerforbenefits.org
 www.mymedicarematters.org
 www.benefitscheckup.org
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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 Medicare
 Easy to navigate
 Clear, simple language
 Answers 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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