Chronic Kidney Disease and Medicare: A Guide for People With Employer Group Health Plan Insurance

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1 Introduction: Should You Apply for Medicare When You Start Dialysis? Health Insurance is a vital and increasingly complex resource. You are a part of a select group that can sign up for Medicare before retirement, with or without Social Security disability income. Deciding whether to enroll in Medicare when you begin dialysis is an important decision that can either save or cost you money. Learning all you can about your employer group health plan (EGHP) insurance and the coordination of EGHP insurance with Medicare can protect you from costly missteps! This guide will help you become familiar with the language of health care insurance and some of the rules about Medicare for kidney failure and commercial health insurance plans. ******************************************************* Three Important Rules of Medicare for People With Chronic Kidney Disease 1. When you enroll in Medicare, sign up for Part A and Part B together. If you sign up for Medicare Part A (hospital) only, you will have to wait until the next open enrollment period to get Part B (outpatient). The open enrollment period is January to March each year. If you sign up for Medicare Part B during open enrollment, your Part B starts in July of that year. So, if you refuse Part B when you first sign up for Medicare, you may have to wait up to 15 months to be able to get Part B coverage! 1 Council of Nephrology Social Workers

2 2. Medicare Part A is free; you pay for Part B. You must pay the Medicare Part B premium if you are working. If you receive Social Security retirement or disability income, the premium is deducted from your check. 3. Never let your Medicare Part B lapse for non-payment. Once you enroll in Medicare Part B, do not cancel it. If you do, when you need to sign up for Part B again, you can face penalties and long delays for Medicare payment even if you pay all the premiums. If you are not able to pay the Part B premium, ask your social worker if you are eligible for assistance. You cannot get this help if Part B has been cancelled. Medicare Entitlement and Kidney Failure Entitlement refers to the reason you are eligible to have Medicare. If you are entitled to Medicare because of chronic kidney failure, the date your Medicare can start depends on your method of treatment. In-Center Hemodialysis: You can get Medicare on the first day of the third full month after you start dialysis. Example: You start center Hemodialysis in March. You are entitled to Medicare as of June 1. Home Dialysis: If you start a home or self-care dialysis training program before the first day of the third full month after you start dialysis, you can get Medicare from the first day of the month you started dialysis. Example: You start dialysis in March and begin home training in May. You are entitled to Medicare as of March 1. Kidney Transplant (without prior dialysis): You can get Medicare the first day of the month of your transplant. If you are evaluated for a transplant and receive a transplant within two months, Medicare can backdate to the month of your evaluation. Example: You are evaluated for a transplant in March. You receive a transplant in May. You are entitled to Medicare as of March 1. 2 Council of Nephrology Social Workers

3 Coordination of Benefits (Medicare and Kidney Failure) You can apply for Medicare now or choose to delay applying for both Part A and Part B of Medicare if you have EGHP insurance from your work or your spouse s work. Your EGHP insurance is your primary health insurance for the first 30 months after you are entitled to Medicare for dialysis or a kidney transplant. Primary health insurance is the one that pays the medical bills first. This 30-month period is called a Medicare secondary payer coordination of benefits period. Should You Apply for Medicare Now if You Have Full Coverage? If you sign up for Medicare, it will be your secondary health insurance during this beginning 30-month period. Medical bills not covered by your primary insurance can be sent to Medicare. Medicare may pay all or part these bills if they are for services Medicare covers. How Do You Obtain Information About Your Health Insurance? You are entitled to get information about your health insurance benefits in writing. Call your health insurance carrier or your employment benefits representative to get your full policy benefits. If You Decide to Wait Until Your 30-Month Coordination of Benefits Period Is Over to Apply for Medicare Apply at least one month in advance. Ask your kidney facility for a Chronic Renal Disease Medical Evidence Report (CMS # 2728). Apply by phone and mail this report, or apply in person at your local Social Security Administration (SSA) office and take it with you. Call SSA to find out where their closest office is located at Let Social Security know the date you want Medicare Parts A and B to start. 3 Council of Nephrology Social Workers

4 Reasons to Consider Taking Medicare While Your Employer Group Health Plan Is Your Primary Insurance Your EGHP policy gives you less than 100% coverage. Look for deductibles and co-pays. Medicare may pay these costs. Your health insurance policy has coverage limits, ceilings, caps, or lifetime maximum benefits. These words indicate your health insurance policy has set a total dollar limit on benefits and will not pay beyond that amount. Your health insurance policy excludes pre-existing medical conditions. This is something to watch out for if you got the insurance recently. If your chronic kidney failure is a pre-existing condition, your insurance can deny coverage for one year. Caution! If in the last six months: 1) you were diagnosed with kidney disease, 2) recommended to get treatment for kidney disease, or 3) you had any treatment for kidney disease, your kidney disease can be considered a pre-existing condition. You lose your full health insurance coverage for any reason. You are planning to get a kidney transplant. If you have Medicare when you get your transplant, Medicare can help pay for anti-rejection drugs. You want to protect yourself against unknowns and are willing to pay for Medicare Part B. These are just examples. Check your coverage to protect yourself! Medicare Entitlement Because of Retirement Age or Disability You are also eligible for Medicare at retirement age or if you have received Social Security Disability payments for two years. If you have Medicare due to age or disability and EGHP insurance, and you have started dialysis or received a kidney transplant, your EGHP is your primary insurance for 30 months. 4 Council of Nephrology Social Workers

5 Resources for Consumers: Medicare: 800-MEDICARE Medicare Coordination of Benefits: Social Security Administration: Booklets for Consumers: Medicare and You (CMS 10050) Medicare Coverage of Kidney Dialysis and Kidney Transplant Services (CMS 10128) Medicare and Other Health Benefits: Your Guide to Who Pays First (CMS 02179) You can get these booklets from Social Security Administration or from your dialysis or transplant facility. 5 Council of Nephrology Social Workers