Medicare Question

Ask Our Experts Beth Witten, Social Worker
1

I had asked Bill Peckham this question, and referred me here.
I’ve always understood it to be that dialyzors have no choice after the 33 month coordination period, and must (by law) become Medicare primary.
In reading Medicare documentation last night it was clear that a dialyzor can choose not to enroll in Medicare right away, but what happens then at the end of the coordination period if a younger ESRD patient doesn’t enroll in Medicare? Must they enroll in Medicare before the end of this period, or will their private insurance (let’s assume group plan through employer) keep covering costs indefinitely?

For whatever reason, I thought there was no choice - that after the coordination period, everyone on dialysis becomes Medicare primary, but now I’m questioning that due to the ambiguity in the Medicare documentation.
Does a dialyzor have a choice? If their work provides private insurance could they opt-out of Medicare indefinitely and just use their private insurance, or are they forced at some point to take on Medicare?

Thanks in advance,
Jonathan

2

Someone who qualifies for Medicare for ESRD can choose whether to enroll in Medicare Part A only or Part A and Part B. After 30 months of Medicare eligibility (whether enrolled or not), an employer plan knows it is only liable for secondary benefits, and most stop paying primary benefits. Charges for dialysis and other care for people with kidney failure is so high that a plan’s lifetime benefit limit may be reached leaving the person without any employer coverage.

You can do what you want, but my advice after >30 years of social work practice is to take Medicare A and B because:

  • Enrolling in Part A protects your rights to get Medicare payment for anti-rejection medications post-transplant any time you have Medicare. If you don’t have Part A when you get a transplant, Medicare will never pay for anti-rejection drugs under Part B and Part D is not supposed to pay for drugs that could be covered under Part B if the person could have had that coverage.
  • Enrolling in Part B keeps “participating providers” – those who agree to accept 100% of Medicare’s allow charge as payment in full. This means that provider can’t bill you for employer plan deductibles and coinsurance or copays if your employer plan pays at least 100% of Medicare’s allowed charge.
  • If you enroll in Part A (free for most) but choose not to enroll in Part B (premium), you may have a gap in coverage if your employer coverage shifts to secondary before Medicare Part B can start. After the “initial enrollment period” that extends 3 months after the month dialysis starts, you can only enroll in Part B from January 1-March 31 annually and Medicare Part B won’t start until July 1. Plus there’s a 10% premium surcharge added to the premium at the time for 12 months you delayed enrolling in Part B after enrolling in Part A.
3

Beth,

I was told by the financial coordiantor at the transplant center that Medicare Part B does not cover anti rejection drugs. She says Part B covers only office visits and that Part D covers the anti-rejection medication, but the co-insurance/deductible is very high?
Currently we have the EHP and our prescription plan is integrated with our medical insurance so after we reach the max out of pocket, the EHP will pay 100% on both medical and prescription drugs. So paying for the post transplant drugs will not be a problem as long as we have the EHP, but am concerned about retirement when we no longer have the EHP.
My question is once you reach 65 and you’re on Medicare and have ESRD, are there any Medicare Plans you can sign up to help cover the costly immunosuppressant drugs, other than Part D which has a high deductible? What other plans are there can the patient(65+yrs old) sign up to fill in the gap for Plan D? Or do you have to be a wealthy person who can afford to pay for all the post transplant drugs and not lose any of your personal assets?

Nic

4

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.
https://www.srtr.org/