Advice for PD patient visiting US

Hi and thanks everyone. I have a couple questions about how to navigate an unusual situation – are there any steps or tips you have for a dialysis patient who will be doing a multi-week stay in the US?

My elderly parent used to live in the US, now lives in India, and is planning on making an extended visit to the US. She has kidney failure and so she started peritoneal dialysis earlier this year, in India, and she will need to continue treatment while visiting the US. Because of past work history she qualifies for Medicare, so she plans to sign up for Medicare, including Part B (Medical coverage) and Part D (prescription drug coverage).

My family is trying to talk with local facilities (in the US, in the city she’ll be visiting) that offer PD, so we can go get a tour, figure out pricing, and do things like that. It seems like her situation is pretty unusual – the local facilities are used to people in the area starting PD, and maybe they’re used to a travelling patient saying “could I please tour your facility because I might start using it,” but it’s a little harder because my parent is not available in person for an intake meeting.

I have 2 main questions:

  1. Is there some specific phrasing or paperwork we should make sure to get from her Indian doctors when doing an international transfer of a current PD patient? Should we preemptively get some kind of general referral or letter from her existing nephrologist in India to send them as part of the initial conversation? Will they need it notarized or something like that?

  2. Is there a set of steps we should be following in sequence? For example, will it be easier to coordinate with the local centers after she signs up for Medicare? Is there a way to connect with a local dialysis social worker before choosing a specific center, or does each center have its own social workers?

I also welcome any other advice from people who have dealt with anything similar. Thanks for your advice!

As you say, this is an unusual situation. I would suggest starting with the Social Security office in the location where she will be living. She may be able to do the business she needs to do with SSA online. Until recently, SSA offices were closed, but now some offices are reportedly open. Under Review Your Information at the link below, she should be able to confirm that she meets the work credit qualifications for Medicare.

SSA also has an office for people eligible for SSA benefits living overseas. I looked up India and found this information:
India
Federal Benefits Unit
United States Embassy
1201 Roxas Boulevard
Ermita, Manila 0930
Philippines
Phone: 632-5301-2000
Fax: 632-8708-9714 or 632-8708-9723
Email: FBU.Manila@ssa.gov
Social Security Office of Earnings & International Operations

When someone starts dialysis in the U.S., the dialysis clinic fills out a form and the doctor at that clinic signs and attests that the patient has irreversible kidney failure requiring dialysis or transplant. The form is CMS 2728. I’ve not heard of this being filled out by a non-U.S. doctor or outside a U.S. dialysis clinic. There is a specific application for ESRD Medicare. Here’s the SSA policy about that.

Here’s a SSA policy about foreign residents.

If she can get proof from SSA or website that she is eligible for Medicare once she applies, that might make it easier to get admitted to a U.S. dialysis clinic. People in the U.S. who start a program to train for home dialysis before the end of their third month of dialysis get Medicare backdated to the month dialysis started. I assume Medicare would be backdated to the first month she’s on PD in the U.S. People have a 7-month initial enrollment period (IEP) around the month they become eligible for Medicare so if your mother is 65 or older, she may have missed that IEP. However, because she now has ESRD, that should give her a new IEP to apply for Medicare Part A and B. Here’s the SSA policy on enrollment periods for Medicare.

So far as Medicare payment, Original Medicare doesn’t cap Part A and B costs, so I’d suggest she apply for a Medicap plan. People 65 or older get 6 months to apply for a Medigap plan to cover Medicare deductibles, coinsurance and copays. She would also need to apply for Part D through an insurance company to cover drugs. As an alternative, she could apply for a Medicare Advantage plan through an insurance company that includes Part A, B and D benefits. Most social workers who work with dialysis and transplant patients have seen negatives associated with MA plans. They often limit choice of providers and out-of-pocket costs may be higher because although MA plans must cap Part A and B out-of-pocket costs, Part D drugs costs aren’t capped.

So far as social workers, dialysis clinics are required to have social workers to help patients meet their psychosocial needs. Most nephrology practices do not employ social workers. Social workers working in dialysis may serve patients in multiple dialysis clinics. I always advise patients to ask for their social worker when needed. When I worked as a social worker, I saw the PD patients when they came to clinic. Today with the COVID-19 pandemic, many clinics are keeping in touch with home patients remotely when patients don’t come to clinic.

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