Introduction to Medicare-2015
Three main types of Medicare health plans are available:
Original Medicare has three parts:
Part A (hospital) covers inpatient care, kidney transplantation, skilled nursing home residence, and hospice care.
Part A has no premium for those who have paid enough Medicare taxes. A premium is an amount a person must pay periodically—monthly or quarterly—for Medicare, other health plan, or drug plan coverage. Part A does have a deductible, an amount a person must pay for health care or prescriptions before the health plan will pay. A person must pay a daily amount for hospital stays that last longer than 60 days.
Part B (outpatient) covers most dialysis treatments and supplies, health care provider fees, and anti-rejection medications for transplant. Part B has a monthly premium based on a person’s income. Rates change each year. After a person pays the deductible each year, Part B pays 80 percent for most covered services as a primary payer. The billing staff of the service provider—hospital or clinic—can calculate how much a person will owe.
Part D (medications) has a premium and covers some medications. Private insurance companies offer different Part D plans approved by Medicare. Costs and coverage vary by plan. A person who has few assets and earns less than 150 percent of the federal poverty level may qualify for extra help to pay Part D premiums and medication costs. The current-year guidelines can be found at www.aspe.hhs.gov/poverty or by calling Social Security at 1–800–772–1213. Information and applications for Part D plans can be found at www.medicare.gov. A person can also apply for Part D with an insurance company that sells one of these plans.
A person can apply for Medicare online at www.ssa.gov or at a local Social Security office. Social Security’s toll-free number is 1–800–772–1213, TTY 1–800–325–0778. A person can call to set up a time to meet with someone at a local office and apply.
A person with ESRD can apply for Medicare at the start of dialysis or at the time of a kidney transplant. The Medicare start date depends on the type of treatment:
Home dialysis, including peritoneal dialysis and hemodialysis at home. Medicare can start the first month of dialysis only if a person trains for home dialysis.
Kidney transplant. Medicare can start the same month as the transplant. In some cases, Medicare could start up to 2 months earlier if the patient is admitted to the hospital and the transplant is delayed. For example, if a patient is admitted to the hospital for a transplant in March and the transplant is delayed until May, payment still begins in March. A transplant financial counselor can provide more information.
In-center dialysis. Medicare will not start until the fourth month of in-center dialysis. For example, if a person starts dialysis in a clinic in July and does not train for home dialysis, Medicare will not start to pay until October 1.
Who Pays first?
Individual plan—not provided by an employer-Medicare always pays first. An individual plan always pays second.
Employer or union group plan- With kidney failure, the employer or union group plan pays first for 30 months* after a person is eligible for Medicare because of kidney failure. The 30-month clock starts whether the person enrolls in Medicare or not. However, the person will eventually have to enroll in Medicare. After the 30 months, Medicare pays first. The employer or union group plan may pay all or part of the rest.
*This time period is called the “Medicare secondary payer coordination period.”
Having Medicare Part B plus another health plan can limit what a person pays out-of-pocket for health care. In some cases, Medicare can limit how much a health care provider charges for services. If a person does not have Part B, the health care provider or dialysis clinic can bill the individual or group health plan and the person at a much higher rate. The person may have to pay what the plan does not pay.
In some situations, a person who has other insurance may be able to save money by not enrolling in Part B until the 30-month coordination period is over. The person would not have to pay the Part B premiums during that period.
Should a person with other insurance wait to start paying for Part B?
YES, if: A person’s plan pays 100 percent of all health care costs during that time.
If a person waits to enroll in both Part A and B, enrollment for both can happen at any time.
If a person takes Part A—waiting to start Part B—the person can only enroll once a year from January 1 through March 31 and Part B will not start until July 1. A person should enroll in Part B in time to prevent a gap in coverage. For example, if the 30-month coordination period ends April 30, an employer or union group plan can stop paying first on May 1. If a person enrolled in Part B by March 31, Part B will not start paying first until July 1. The person will have large bills for May and June.
NO, if: The person has to pay yearly deductibles, copays, or coinsurance, which are fees not covered by the insurance plan. Medicare may or may not pay those fees. However, having Medicare limits what a dialysis clinic can charge. The premium for Part B usually costs less than paying deductibles, copays, or coinsurance.
Where can I get more information about Medicare’s kidney failure treatment coverage?
These booklets from Medicare offer more information about Medicare’s kidney failure treatment coverage:
Medicare Coverage of Kidney Dialysis & Kidney Transplant Services
Publication No. CMS 10128
Internet: www.medicare.gov/Pubs/pdf/10128.pdf (PDF, 743 KB)*
Medicare for Children with End-Stage Renal Disease
Publication No. CMS 11392
Internet: www.medicare.gov/Pubs/pdf/11392.pdf (PDF, 6,617 KB)*
Medicare Advantage plans, also called Part C, are sold by insurance companies. Medicare must approve Medicare Advantage plans. Each Medicare Advantage plan must cover Part A and Part B services and may cover other services, too. Medicare Advantage plans may have Part D medication coverage. If not, a person can buy a Part D plan separately. Medicare Advantage plans are not all the same. A person with failing kidneys who is thinking of choosing a Medicare Advantage plan should ask about the rules of the plan. The rules may specify which health care providers or hospitals a person may use. The plan may require a referral from a primary care provider to see a specialist. The plan may not cover medical expenses incurred during travel. How much a person has to pay out-of-pocket each year will vary by plan. People who have a Medicare Advantage plan cannot have a Medigap plan to help pay out-of-pocket costs. See the section on Medigap.
Four types of Medicare Advantage plans are available:
health maintenance organizations (HMOs)
preferred provider organizations (PPOs)
private fee for service plans
special needs plans for certain groups
Those already on dialysis cannot join most Medicare Advantage plans. However, a person who had a Medicare Advantage plan before kidney failure can keep the plan. In some regions, special needs plans are designed for those on dialysis. A person can call 1–800–MEDICARE (1–800–633–4227) to learn if region-specific special needs plans are available for those on dialysis.
Special Thanks to NIH