A good overview of ESRD Medicare Coverage

This was published in the Medicare Rights Center's May/June 2011 Newsletter

http://www.medicarerights.org/pdf/thecounselor.pdf

Medicare and ESRD
Endstage renal disease is when a person’s kidneys are no longer able to function or almost no longer able to function. People who have ESRD usually need dialysis or a kidney transplant.

Eligibility
Someone who has ESRD is eligible for Medicare no matter how old they are as long as they are getting dialysis or have had a kidney transplant. They must also have enough Social Security work quarters to qualify for Railroad Retirement Board or Social Security benefits. For someone who has ESRD, the required work quarters can come from a spouse or parent if the person is a dependent child. Someone who is eligible for Medicare based on ESRD should enroll by contacting Social Security, even if they are aretired railroad worker.

For someone who has ESRD, when their Medicare starts depends on if they are getting dialysis, are being taught how to give themselves dialysis treatment at home, or if they are getting a kidney transplant.

For people who are getting dialysis, their Medicare begins the first day of the fourth month they are receiving dialysis. Individuals who are getting dialysis and participate in a self-dialysis training program that will teach them how to give themselves dialysis at home, can get Medicare earlier. Someone undergoing this training can get Medicare retroactive to their first month of dialysis.

For individuals who are getting a kidney transplant, their Medicare will begin the month they are admitted to a Medicare-approved hospital for a kidney transplant, or the services needed before the transplant. Medicare will begin the month of admission as long as the transplant is within that month or the following two months. If the person’s transplant is delayed, their Medicare will begin two months before their transplant.

Most people who are eligible for Medicare due to ESRD have Original Medicare. People with ESRD usually cannot have a Medicare Advantage plan. There are a few exceptions. Someone with ESRD might be able to join a Medicare Advantage plan if there is a Special Needs Plan in their area that accepts ESRD patients. Also, someone who has ESRD might also be in a Medicare Advantage plan if they were in this plan before having ESRD.

Coordination of Benefits
Medicare coordinates differently with employer insurance for people with ESRD than it does for people who have Medicare due to age or disability. For people who have Medicare due to ESRD there is what is called a 30-month coordination period. The 30-month coordination period is the first 30 months that someone with ESRD Medicare has Medicare. During this coordination period, their employer insurance is primary. This includes any type of employer insurance, including COBRA and retiree insurance. Even if your client does not sign up for Medicare when they become eligible, the 30- month coordination period begins when they first qualify for Medicare.

After the 30-month coordination period, Medicare will pay primary for all Medicare covered services and your client’s employer insurance, if they have insurance from their employer, will pay second.

Some people who feel that they are adequately covered by their employer health plan may delay enrollment in Medicare in order to avoid having to pay the monthly Part B premium. For people who choose to do this, they should delay enrollment in both Part A and Part B when they become eligible so that they do not incur a penalty later. If they only enroll in Part A and take Part B later, they will have to pay a penalty. It is best for people in this situation to enroll right before their 30-month coordination period ends so that they can avoid having any gaps in coverage. If someone waits until after their 30-month coordination period to enroll in Medicare, they will have to wait until the General Enrollment Period to enroll. The General Enrollment Period is January through March of each year. If someone enrolls during this period, their coverage will begin July 1 of that year. This could lead to someone having gaps in their coverage if they do not enroll during their 30-month coordination period.

It is important to note that in order for Part B to cover someone’s immunosuppressive drugs after a transplant, they must have had Part A when they got the transplant. If they did not have Part A when they got the transplant, their immunosuppressive drugs should be covered under Part D if they are enrolled in it.

Termination of Medicare
If someone has Medicare due to ESRD and their condition improves, their Medicare coverage may end. If your client no longer needs dialysis their Medicare coverage will end 12 months after the month in which they had their last dialysis treatment. If your client had a successful kidney transplant their Medicare will end 36 months after the transplant. A kidney transplant is considered successful if it lasts for 36 months without rejection.

If someone starts getting dialysis or has a kidney transplant within 12 months of stopping dialysis, their Medicare will continue. It will also continue for someone who starts getting dialysis or has another kidney transplant within 36 months of having a transplant.

If an individual’s Medicare coverage due to ESRD ends and then they qualify for this coverage again, they will not have to wait for their Medicare coverage to start. Their Medicare will begin the first of the month they start dialysis again, or the first of the month they have a kidney transplant. They will also have another 30-month coordination period where their employer will pay first and Medicare pays second.