Section 1: Medicare Basics
What is Medicare?
Medicare is health insurance for:
■ People 65 and older
■ People under 65 with certain disabilities
■ People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)
What Medicare covers
Medicare Part A (Hospital Insurance) helps cover:
■ Inpatient care in hospitals
■ Inpatient care in skilled nursing facilities (not custodial or long-term care)
■ Hospice care
■ Home health care
Medicare Part B (Medical Insurance) helps cover:
■ Services from doctors and other health care providers
■ Outpatient care
■ Home health care
■ Some preventive services
For more details about what Medicare covers, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
What Medicare costs
Most people don’t have to pay a monthly premium for Part A because they (or a spouse) paid Medicare taxes while they were working.
Most people must pay a monthly premium for Part B. The standard Part B premium for 2012 is $99.90 per month, although it may be higher based on your income. Premium rates can change yearly. You need Part B to get the full benefits available under Medicare for people with ESRD, and you must pay the premium to get Part B. For more information about the Part B premium, visit www.socialsecurity.gov, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
Paying for Part B
When you sign up for Part B, the premium is usually taken out of your monthly Social Security or Railroad Retirement payment. If you don’t get one of these payments, Medicare sends you a bill for your Part B premium every 3 months. You should get your Medicare premium bill by the 10th of the month. If you don’t get your bill by the 10th, call Social Security.
Who’s eligible?
You can get Medicare no matter how old you are if your kidneys no longer work, you need regular dialysis or have had a kidney transplant, and:
■ You’ve worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee.
■ You’re already getting or are eligible for Social Security or Railroad Retirement benefits.
■ You’re the spouse or dependent child of a person who meets either of the
requirements listed above.
You must also file an application, and meet any waiting periods that apply.
If you qualify for Part A, you can also get Part B. As noted above, enrolling in Part B is your choice, but you’ll need both Part A and Part B to get the full benefits available under Medicare to cover certain dialysis and kidney transplant services.
If you don’t qualify for Medicare, you may be able to get help from your state to pay for your dialysis treatments. More Info.
Call Social Security at 1-800-772-1213 for more information about the required amount of time needed under Social Security, the Railroad Retirement Board, or as a government employee to be eligible for Medicare based on ESRD. TTY users should call 1-800-325-0778. You can also visit www.socialsecurity.gov.
Medicare plan choices
Medicare generally offers different choices for how you can get your health and prescription drug coverage, although the choices may be limited if you have ESRD. Your costs will vary depending on your coverage and the services you use.
If you have ESRD and you’re new to Medicare, you’ll most likely get your health care through Original Medicare. Original Medicare is managed by the Federal government.
You can go to any doctor or supplier that’s enrolled in and accepts Medicare and is accepting new Medicare patients, or to any participating hospital or other facility. You pay a set amount for your health care (deductible) before Medicare pays its share. Then, Medicare pays its share, and you pay your share (coinsurance or copayment) for covered services and supplies.
When you have Original Medicare, you can add prescription drug coverage by joining a Medicare Prescription Drug Plan (Part D). Private companies approved by Medicare run these plans. Different plans cover different drugs, but most medically-necessary drugs must be covered. More Info.
You usually can’t join a Medicare Advantage Plan (like an HMO or PPO) if you already have ESRD, and haven’t had a kidney transplant. However, you may be able to join a Medicare Special Needs Plan, a type of Medicare Advantage Plan for people with certain chronic diseases, if one is available in your area for people with ESRD. These plans must provide all Part A and Part B health care and services, as well as Medicare prescription drug coverage. You also may be able to join a Medicare Advantage Plan if you’re already getting your health benefits (for example, through an employer health plan) through the same organization that offers the Medicare Advantage Plan. While you’re in a Medicare Advantage Plan, the plan will be the primary provider of your health care coverage. You must use your Medicare Advantage Plan ID card instead of your red, white, and blue Medicare card when you see your doctor or get other kinds of health care services.
If you had ESRD, but have had a kidney transplant, and you still qualify for Medicare benefits based on your age or a disability, you can stay in Original Medicare, or join a
Medicare Advantage Plan.
If you have ESRD and are enrolled in a Medicare Advantage Plan that stops being offered in your area, you have a one-time right to join another Medicare Advantage Plan if one is available in your area. You don’t have to use your one-time right to join a new plan immediately. If you change directly to Original Medicare after your plan stops providing coverage, you will still have a one-time right to join a Medicare Advantage Plan at a later date as long as the plan you choose is accepting new members.
For more information about your Medicare plan choices, look at your
“Medicare & You” handbook. You can visit www.medicare.gov/publications to view the handbook. You can also call 1-800-MEDICARE (1-800-633-4227) to get more information. TTY users should call 1-877-486-2048.
How to sign up for Medicare
If you’re eligible for Medicare because of ESRD, you can enroll in Part A and Part B by visiting your local Social Security office or by calling Social Security at 1-800-772-1213.
TTY users should call 1-800-325-0778.
If you qualify for Part A, you’ll also be offered Part B. As noted above, you need both parts to get all the Medicare benefits available for ESRD, and there’s a premium for Part B. If you decide not to get Part B right away, you can only enroll January 1–March 31 each year. Your coverage will begin on July 1. Also, the cost of Part B will go up 10% for each 12-month period that you could have had Part B but didn’t sign up for it. If you have employer or union group health plan coverage, see more info.
Note: If you’re already enrolled in Medicare based on age or disability, and you’re already paying a higher Part B premium because you didn’t enroll in Part B when you were first eligible, the penalty will stop when you become entitled to Medicare based on ESRD. Call your local Social Security office to make an appointment to re-enroll in Medicare based on ESRD.
When Medicare coverage begins
When you enroll in Medicare based on ESRD and you’re on dialysis, Medicare coverage usually starts the first day of the fourth month of your dialysis treatments. For example, if you start getting your dialysis treatments in July, your Medicare coverage would start on October 1.
July: First month of dialysis
August: Second month of dialysis
September: Third month of dialysis
October: Fourth month of dialysis. Medicare coverage begins.
If you’re covered by an employer or union group health plan, for the first 30 months you’re covered by Medicare, your employer or union group health plan will pay first on your health care bills, and Medicare will pay second. More Info.
If you don’t have employer group health plan coverage, there are other types of insurance and programs that may help to pay some of your health care costs. More Info.
Medicare coverage can start as early as the first month of dialysis if you meet all of the following conditions:
■ You take part in a home dialysis training program offered by a Medicare-approved training facility to teach you how to give yourself dialysis treatments at home.
■ Your doctor expects you to finish training and be able to do your own dialysis treatments.
Medicare coverage begins the month you get a kidney transplant. Medicare coverage can begin the month you’re admitted to a Medicare-approved hospital for a kidney transplant (or for health care services that you need before your transplant) if your transplant takes place in that same month or within the following 2 months.
Example: Mr. Green will be admitted to the hospital on March 11 for his kidney transplant. His Medicare coverage will begin in March. If his transplant is delayed until April or May, his Medicare coverage will still begin in March.
Important: Medicare won’t cover surgery or other services needed to prepare for dialysis (such as surgery for a blood access [fistula]) before Medicare coverage begins. However, if you complete home dialysis training, your Medicare coverage will start the month you begin regular dialysis, and these services could be covered.
Medicare coverage can begin 2 months before the month of your transplant if your transplant is delayed more than 2 months after you’re admitted to the hospital for the transplant or for health care services you need before your transplant.
Example: Mrs. Perkins was admitted to the hospital on May 25 for some tests she needed before her kidney transplant. She was supposed to get her transplant on June 15. However, her transplant was delayed until September 17. Therefore, Mrs. Perkins’
Medicare coverage will start in July, 2 months before the month of her transplant.
Note: This waiting period will start even if you haven’t signed up for Medicare. For example, if you don’t sign up until after you’ve met all the requirements, your coverage could begin up to 12 months before the month you apply.
When Medicare coverage ends
If you’re eligible for Medicare only because of permanent kidney failure, your Medicare coverage will end:
■ 12 months after the month you stop dialysis treatments
■ 36 months after the month you have a kidney transplant
Your Medicare coverage will be extended if:
■ You start dialysis again, or you get a kidney transplant within 12 months after the month you stopped getting dialysis
■ You start dialysis or get another kidney transplant within 36 months after the month you get a kidney transplant
Important: Remember, you need both Part A and Part B to get the benefits available under Medicare for people with ESRD. If you don’t pay your Part B
premium or if you choose to cancel it, your Part B coverage will end.
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How Medicare works with employer or union group health plan coverage
If you’re eligible for Medicare only because of permanent kidney failure, your eligibility usually can’t start until the fourth month of dialysis. This means if you have coverage under an employer or union group health plan, that plan will be the only payer for the first 3 months of dialysis (unless you have other insurance).
If your employer or union plan doesn’t pay all costs for dialysis, you may have to pay some of the costs. You may be able to get help paying these
costs. More info.
Once you become eligible for Medicare because of permanent kidney failure (usually the fourth month of dialysis), there will still be a period of time, called a “coordination period,” when your employer or union group health plan will continue to pay your health care bills. However, if your plan doesn’t pay 100% of your health care bills, Medicare may pay some of the remaining costs. This is called “coordination of benefits,” under which your plan “pays first” and Medicare “pays second.” During this time, Medicare is called the secondary payer. This coordination period lasts for 30 months.
When the 30-month coordination period starts
The waiting period for eligibility will start even if you haven’t signed up for Medicare. The same thing is true of the 30-month coordination period, which starts the first month you would be eligible to get Medicare because of permanent kidney failure (usually the fourth month of dialysis), even if you haven’t signed up for Medicare yet. For example, if you start dialysis and are eligible for Medicare in June, the 30-month coordination period will start September 1, the fourth month of dialysis even if you don’t have Medicare.
If you take a course in self-dialysis training or get a kidney transplant during the 3-month waiting period, the 30-month coordination period will start earlier. During this 30-month period, Medicare will be the secondary payer.
Important: If you have employer or union group health plan coverage, tell your health care provider that you have this coverage. This is very important to make sure that your services are billed correctly.
When the 30-month coordination period ends
At the end of the 30-month coordination period, Medicare will pay first for all Medicare-covered services. Your employer or union group health plan coverage may still pay for services not covered by Medicare. Check with your plan’s benefits administrator.
How the 30-month coordination period works if you enroll in Medicare more than once There’s a separate 30-month coordination period each time you enroll in Medicare based on permanent kidney failure. For example, if you get a kidney transplant that continues to work for 36 months, your Medicare coverage will end (unless you have Medicare because you’re 65 or older or you have a certain disability). If after 36 months you enroll in Medicare again because you start dialysis or get another transplant, your Medicare coverage will start right away. There will be no 3-month waiting period before Medicare begins to pay. However, there will be a new 30-month coordination period if you have employer or union group health plan coverage.
Do I have to get Medicare if I already have an employer or union group health plan?
No, but you should think carefully about this decision. If you get a kidney transplant, you’ll need to take immunosuppressive drugs for the rest of your life, so it’s important to know if they’ll be covered. If you’re entitled to Medicare only because of ESRD (you’re not over 65 or disabled), Part B will only cover your immunosuppressive drugs (more info. ) if you already had Part A at the time of the transplant, and the transplant surgery was performed at a Medicare-approved facility.
Note that Part B will only cover the immunosuppressive drugs after you’re enrolled in Part B. There won’t be any retroactive coverage.
Note: If you don’t meet the conditions for Part B coverage of immunosuppressive drugs, you may be able to get coverage by joining a Medicare Prescription Drug Plan. More info.
If your group health plan coverage has a yearly deductible, copayment, or coinsurance, enrolling in Part A and Part B could help pay those costs during the coordination period.
If your group health plan coverage will pay for most or all of your health care costs (for example, if it doesn’t have a yearly deductible), you may want to delay enrolling in Part A and Part B until the 30-month coordination period is over. If you delay enrollment, you won’t have to pay the Part B premium for coverage you don’t need yet. After the 30-month coordination period, you should enroll in Part A and Part B. Your Part B
premium won’t be higher because you delayed your enrollment. If your group health plan benefits are decreased or end during this period, you should enroll in Part A and Part B
as soon as possible.
For more information about how employer or union group health plan coverage works with Medicare
■ Get a copy of your plan’s benefits booklet.
■ Call your benefits administrator, and ask how the plan pays when you have Medicare.
Medicare for children with ESRD
Medicare covers people of all ages who have ESRD. Your child can be covered if you or your spouse has worked the required amount of time under Social Security, the Railroad Board, or as a government employee. Your child can also be covered if you, your spouse, or the child gets Social Security or Railroad Retirement benefits. Medicare can help cover your child’s medical costs if your child needs regular dialysis because his or her kidneys no longer work, or if he or she has had a kidney transplant.
Use the information in this booklet to help answer your questions, or visit www.medicare.gov/publications to view the brochure “Medicare for Children with End-Stage Renal Disease: Getting Started.” You can also contact your local Social Security office, or call 1-800-772-1213. TTY users should call 1-800-325-0778.
