Hi. My partner has just received a new kidney (10/1/2024). He’s 51 and plans to go back to work after recovery. He is currently on FMLA/short-term disability, and has active, private insurance with Cigna through his employer. He will not be retiring until 55. We are dual income, have diligently saved, and can afford to pay our portion of the hospital bills and medications (at least thus far). He was not in dialysis prior to transplant. We got lucky, and he received a kidney match, just as he was about to start.
That said, our social worker at the hospital has encouraged him to sign up for Medicare within the 36 month (post transplant) period. She says it’s to avoid penalty at retirement. We have done quite a bit of research on Medicare, but still find it very confusing. We could use some help clarifying how we should proceed with enrollment. We are aware that there were some rule changes regarding medication coverage in 2023, and have been going through all the ESRD/Transplant brochures to try and get up to date.
Here’s what we propose to do:
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My partner will enroll in Medicare Part A immediately. There is no premium associated with enrollment, Cigna will remain his primary insurance provider till month 30 (post-transplant). Medicare will become primary for months 30-36, with Cigna secondary. He must also enroll in part A within the same month that he received his transplant (so by October 31) to negate potential coverage restrictions to his benefits, when he becomes eligible after retirement.
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He should wait to enroll in Medicare Part B until month 30 (post transplant), so he will only pay a premium for 6 the months (30-36), when Medicare becomes primary. This strategy reduces our financial burden as we would only have fund both the Medicare, and his private insurance premiums for 6 months. This strategy would also avoid any potential financial penalties to his Medicare premium when he retires in his 60’s. Lastly, it would ensure total coverage of his immunosuppressants, when he becomes eligible after retirement.
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He does not need to enroll in Medicare Part D within the 36 month period post transplant, because his Cigna prescription plan is already considered “creditable” by Medicare and immunosuppressants are covered by Medicare Part B. No penalty should be incurred when he enrolls in Part D after retirement.
Is our assessment correct? We would be grateful for any insight/validation you can provide.
Thank you!
Medicare enrollment can confusing in part because there are different rules for people eligible for Medicare due to age and disability and those eligible due to ESRD. People with Medicare due to age or disability can choose to delay enrolling in Part B under a “special enrollment period” without premium penalty or gap in coverage.
However, people eligible for Medicare due to ESRD have no “special enrollment period” to enroll late in Part B without a premium penalty and without having a potential gap in primary coverage. Delay enrolling in Part B and he will only be able to enroll in it during the general enrollment period (January-March annually) and Part B will start the month after he enrolls (used to be July 1). Here’s the Social Security policy that advises representatives to tell people with ESRD to either take Part A and B together or waive them both until after the 30-month Medicare Secondary Payer period ends. See “F” at
He must have Part A the month of the transplant to ever have immunosuppressant coverage whenever he has Part B. So, my advice is to enroll in both Part A and B. Medicare would be his secondary payer for the whole 36 months. Medicare may or may not pay anything on claims as a second payer. However, if he has Medicare A and B, providers that “accept Medicare assignment” (agree to accept Medicare’s allowed charge) cannot charge him for any part of a bill his insurance doesn’t pay as long as the charge was for a Medicare-covered service and the amount his insurance paid is at least 100% of Medicare’s allowed charge. Most providers bill commercial insurance much more than Medicare so this might save what his Medicare premium would cost.
Thanks so much for your help! We’ve reviewed the information provided, and are proceeding to get him enrolled. The earliest interview he could get is December 2. Does that still count as having “applied” within his transplant month, or do we need to look into ways to expedite the process.
Wow! I’ve heard SSA is backed up, but I’m surprised they don’t have an appointment before December. Back when I worked in dialysis, people could apply over the phone and SSA would send the application to the patient to sign. You might suggest that he call SSA back and ask about that option. Even if he can’t apply over the phone, the good news is that he can ask for Medicare to be backdated to when he became eligible due to transplant and ask for it to backdate to October 1. I’d suggest he ask for both Part A and B to start October 1. He will owe premiums for Part B starting in October. When someone is under 65 and not getting Social Security benefits, SSA normally bills quarterly. He’ll be able to set up a Medicare login and can pay online using credit, debit, HSA or bank checking or savings account. If he sets up an “easy pay” account he can have the premium automatically deducted from his checking or savings account monthly. That’s easier to afford than paying quarterly. Here’s info on how to pay for Medicare Part A or B. He should not have a premium for Part A assuming he has enough credits on his work record or on yours as his spouse.
I applied while I was in the hospital and got an appointment within a month