Medicare and Group Health Coverage for People with End-Stage Renal Disease ESRD

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Medicare and Group Health Coverage for People with
End-Stage Renal Disease (ESRD) (Permanent Kidney Failure)

Question: I have ESRD and group health coverage. Who pays first?

Answer: If you are eligible to enroll in Medicare because of End-Stage Renal Disease (permanent kidney failure), your group health plan will pay first on your hospital and medical bills for 30 months, whether or not you are enrolled in Medicare and have a Medicare card. During this time, Medicare is the secondary payer. The group health plan pays first during this period no matter how many employees work for your employer, or whether you or a family member are currently employed. At the end of the 30 months, Medicare becomes the primary payer. This rule applies to all people with ESRD, whether you have your own group health coverage or you are covered as a family member.

Example: Bill has Medicare coverage because of permanent kidney failure. He also has group health plan coverage through the company he works for. His group health coverage will be his primary payer for the first 30 months after Bill becomes eligible for Medicare. After 30 months, Medicare becomes the primary payer.

Question: Can a group health plan deny me coverage if I have permanent kidney failure?

Answer: No. Group health plans cannot deny you coverage, reduce your coverage, or charge you a higher premium because you have ESRD and Medicare. Group health plans cannot treat any of their plan members who have ESRD differently because they have Medicare.

Question: If I have additional question on my Medicare coverage, who do I call?

Answer: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired)

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Medigap Policies for People Under Age 65
With a Disability or End-Stage Renal Disease

A Medigap policy is a health insurance policy sold by private insurance companies to help you pay the medical costs the Original Medicare Plan does not cover.

Question: If I have Medicare and I want to enroll in mine or my spouse's employer group health plan, can I stop my Medigap policy?

Answer: The Ticket to Work and Work Incentive Improvement Act of 1999 gives you the right to suspend a Medigap policy. If you are under 65, have Medicare, and have a Medigap policy, you have the right to suspend your Medigap policy. This lets you suspend your Medigap policy benefits and premiums, without penalty, while you are enrolled in your or your spouse's employer group health plan.

If, for any reason, you lose your employer group health plan coverage, you can get your Medigap policy back. You must notify your Medigap insurance company that you want your Medigap policy back within 90 days of losing your employer group health plan coverage.

Your Medigap benefits and premiums will start again on the day your employer group health plan coverage stopped. The Medigap policy must have the same benefits and premiums it would have had if you had never suspended your coverage. Your Medigap insurance company can't refuse to cover care for any pre-existing conditions you have. So, if you are disabled and working, you can enjoy the benefits of your employer's insurance without giving up your Medigap policy.

Question: If I have additional question on my Medicare coverage, who do I call?

Answer: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired)