Before the financial counselor talks with anyone else, it sounds like she needs more information about Medicare coverage of dialysis and transplant. Here’s a booklet that explains Medicare. You might want to share the link with her.
Medicare Part B DOES cover anti-rejection drugs if the patient has Part A the month of the transplant. Part D only covers anti-rejection drugs if someone didn’t have Part A the month of transplant. If someone didn’t take Medicare when first eligible, people can request to backdate Part A up to 12 months to cover the month of transplant.
When you’re new to dialysis and have an employer group plan, that plan pays first for 30 months from when the patient is eligible for Medicare. If PD was your husband started PD training before the end of his 3rd month of dialysis, Medicare A and B should be effective the first day of the first month of dialysis, no matter whether that first treatment was HD or PD.
For the first 30 months, Medicare is a secondary payer to the employer plan. Dialysis and other providers often charge employer plans more than the Medicare approved charge. The advantage of having Part B then is that providers that accept Medicare assignment (all dialysis and transplant programs and many others) can’t bill you anything (deductibles, coinsurance, copays) if his employer plan pays at least 100% of Medicare’s approved charge. After the 30-month period, Medicare becomes primary and the employer plan pays secondary. You might want to find out how your husband’s plan coordinates benefits with Medicare. Some pay Medicare’s out-of-pocket costs in full but others only pay part. The good news is that Medicare’s allowed charge is much less than a provider’s charge to commercial insurers.
Unless your husband has another reason for Medicare besides ESRD, Medicare only lasts 36 months after transplant. However, when your husband turns 65, he’ll be eligible for Medicare again and as long as he had Part A for his transplant, Part B will cover his immunos again. Unless he’s still working, Medicare will be primary and he can buy a Medigap plan that will pick up most or all of what Medicare doesn’t pay on Medicare covered services. Federal law protects people from being denied Medigap coverage due to a pre-existing condition for 6 months after they turn 65. Curently in CA there aren’t similar protections for people under 65 so it’s good your husband has a job with good insurance.
So far as plans to choose at 65, I’d choose Original Medicare, a Medigap plan and Part D vs. Medicare Advantage. In my experience and from what I’ve heard from other social workers, Medicare Advantage plans work OK for those who are healthy, but if you have a health condition and want to be able to see the doctor you want to see and go to the hospital you want to use, you have more freedom of choice with Original Medicare. MA claim to give you more benefits, but those plans have more limits on providers, drugs, etc. than Original Medicare, Medigap and Part D.
I’ve heard California wait times are long. Of course waiting time depends on a number of factors, including blood and tissue type as well as antibody level. Some people list at more than one transplant program under different organ procurement organizations (OPOs) to try to get a kidney sooner. You might ask about the transplant program’s wait times and ask about double listing when you go to the transplant education program. There’s a website where you can find out how long to transplant at different hospitals in your area. Select kidney and insert your zip code in the search. You can change the distance if you could get to a program fast enough. You can click on the reports to the left of the transplant program’s name to get the info about time to transplant.