Medicare and transplant catch 22.... 21 days and counting

I recently went through all the tests for transplant and passed with flying colors until we got to the insurance part. I have insurance with a private carrier that I got prior to dialysis which is relatively inexpensive ($89) on a per month basis plus about $450 in co-pays for dialysis treatments (home hemo). Both the major hospitals have told me they will not put me on the list for transplant unless I switch to medicare as primary. If I switch I will lose my advantage plan and my insurance broker says no medigap or secondary insurer will pick me up because of the dialysis. I simply can not afford to pay 20% of the treatment costs. Anyone know of any way out of this catch 22? I have to make a decision prior to open period closing Dec. 10?

Can you be more specific about what insurance you have? is it through an employer or not? You say you have a insurance through a private carrier that you got before you started on dialysis, but later you say if you switch to Medicare you’ll lose your “Advantage plan.” Is your private carrier plan a Medicare Advantage plan? If so, did you get it due to age 65 or disability?

These transplant programs may be reacting to the fact that they have had patients who had problems with Medicare Advantage plans and transplant and post-transplant coverage. If you have a Medicare Advantage plan, it should cover the same anti-rejection medications under its standard benefit (not its Part D) that traditional Medicare covers under Part B. To find out what your costs would be so you can share this with the transplant program, I’d suggest you find out from the transplant programs their exact protocol for immunosuppression (drug, dose, quantity) for the first year. Find out from your plan what your copay would be for these drugs. Ask if the plan has a cap on the amount you have to pay out-of-pocket each year and whether the cost of the immunossuppressant drugs would be counted under that cap. Can you afford that? If not, consider raising funds for those costs and sharing this plan with the transplant program. I’ve heard of patients that have done this through organizations that are non-profits that administer the money for patients and are able to give tax receipts to donors. You can find these programs on this website:

NOTE: Traditional Medicare’s Part B premium for those earning less than $85,000/year (single person) will be $99.90/month in 2012-- not much more than you’re paying now. Traditional Medicare will have a deductible of $140 in 2012 and Part B pays 80% of covered charges. What percent does your insurance pay per home hemo treatment?

To confirm what your insuance broker is telling you, you might want to contact your state insurance department ( or state health insurance assistance program (find under “helpful contacts” on the site) to ask if your state has any Medigap plans for people your age with kidney failure. Be sure to tell them you are currently insured and how.

One thing to point out to the transplant program is that if you obtained your health plan prior to having kidney failure, you won’t lose this coverage 36 months after your have a transplant like you would with Medicare if the only reason you have it is due to ESRD. And if you can afford (or raise the funds to afford) the copay for your immunosuppressants, that should be what they want/need to know. Transplant programs just want to be sure that they don’t put a new kidney in someone who can’t afford or won’t take care of it.

Finally, when you say you have to make a decision prior to the end of the open enrollment period, what enrollment period are you referring to? Part D’s open enrollment period this year ends December 7. Part D as a stand-alone plan or as part of a Medicare Advantage plan will not pay for immunosuppressant drugs if you have Medicare at the time of transplant and get your transplant at a Medicare approved transplant program. Part D may pay for other drugs that you will need pre- and post-transplant.

Beth, I have an advantage plan I got when I turned 65 prior to dialysis. My advantage plan covers all but a $25 co-pay per dialysis treatment 5 days a week or roughly $500 per month. I have been told medicare will automatically become the primary after 30 months with ESRD and my advantage plan becomes the secon dary…is this true? Thanks for the info and I will look into it!

People who are eligible for Medicare have a choice of taking traditional Medicare or a Medicare Advantage (MA) plan. You signed up for a Medicare Advantage plan and that IS your Medicare. It won’t change to Original (traditional) Medicare unless you want to switch.

MA plans typically require you to go to certain providers to get the highest rate of payment or to get a referral to see specialists. People with MA plans can’t have a Medigap plan to pay the deductibles, copays or coinsurance that Medicare leaves. So people with MA plans must pay those costs out of pocket. Until recently, MA plans could require members to pay an unlimited amount out-of-pocket, which was a concern to healthcare providers who worried their patients would not be able to afford care. They have encouraged their patients to take Original Medicare and buy a Medigap plan to avoid having those large out-of-pocket costs.

Recently regulations changed and now MA plans cannot charge their members more out-of-pocket for Part A and Part B services(both dialysis and immunosuppressants are under Part B) provided by in-Network providers than the limit set by the Centers for Medicare & Medicaid Services each year. Plans can set their own voluntary limit which lower than the limit CMS sets. If I’m understanding this recent change correctly, in 2012, MA plans can set a voluntary out-of-pocket limit for Part A and B services from in-Network providers at $0-$3,400. The mandatory limit set by CMS for 2012 is $6,700. If you’re going to an in-Network dialysis provider, the $500 per month you’re paying for your home hemodialysis almost reaches that limit.

Here’s a FAQ about Medicare Advantage plans’ coverage that you might want to show to the transplant center. I’d ask your MA plan to give you in writing what it’s Part A/B cap is so you can share that with the transplant center. Ask the transplant center what you need to show to prove that you have the income and assets to pay that amount each year.

Your Medicare Advantage plan is based on your age and not your ESRD condition so you will not lose this coverage as long as you pay your premium and as long as the plan operates in your area. If otherwise your transplant evaluation was good besides the fact that you have an MA plan and the transplant center refuses to accept documentation from the MA plan about the annual cap on out-of-pocket costs and your have documentation of your ability to pay that amount, I’d contact your state survey agency and file a complaint against the transplant program for discrimination against you as a Medicare beneficiary.