What Medicare pays for...or not

I am a bit confused about the role of Medicare regarding ESRD patients who are younger than 65.

I am 53 and have private insurance through my husband’s employer. As I understand it, once I start dialysis, that private insurance will pay 100% of my medical expenses, including dialysis, just as it does now. After 30 months, Medicare will pay for 80% of “allowable” costs and my private insurance will pick up the other 20%, despite the fact that I am younger than 65 (the special ESRD provision). Is that right so far?

Here’s my question…will Medicare pick up the costs of non-dialysis medical expenses? Let’s say I am on dialysis and am past the 30 month cut-off point, and I break my leg. Nothing to do with dialysis. Does Medicare pay for the expenses incurred? Or would my private insurance company be billed?

Thank you.

When you start dialysis, your husband’s insurance will be billed for the first 30 months that you’re eligible for Medicare whether you take Medicare or not. Medicare Part A is free if you or your husband have enough work credits, which I suspect one or both of you have. Medicare Part B has a premium that is based on your joint income. The premium for Part B generally goes up every year. Part A pays for hospital services. Part B pays for outpatient services including doctors, dialysis and much more. The advantage to having Medicare Part B is that any provider that is a “participating provider” (accepts 100% of what Medicare allows as payment in full) has to write off anything your husband’s insurance doesn’t pay as long as that insurance pays at least 100% of what Medicare allows. Often the difference you’d have to pay in deductibles, copays, or coinsurance is significantly higher than the Medicare premium. However, some people choose not to take Medicare Part B because it does have a premium. However, the downside of doing this is that if you take Part A and waive Part B, you can only sign up for Part B each January through March and Medicare Part B won’t take effect until that July 1. Some patients have been left with a gap in insurance because they forgot to enroll in time to have Medicare Part B in effect by the time their employer plan switched to be a secondary payer. Also, there is a 10% premium penalty for Part B for each 12 months you delay enrolling in it after taking Part A. My advice is to take Part A and B together or choose to enroll in both parts of Medicare in time for it to take effect at the end of the 30-month coordination period.

Many people believe that when someone gets Medicare for dialysis, it only covers dialysis, but that’s not true. When you have Medicare because you have kidney failure and need dialysis or a transplant, it covers ALL Medicare covered services. So…if you broke your leg or you needed a flu shot or any other preventive care Medicare covers, it could be billed as a secondary payer during the first 30 months you have Medicare and as your primary payer after that as long as you have Medicare. You should read your husband’s policy or talk with the benefits folks at his company to find out how that plan works with Medicare. It should pay for anything as a primary payer that Medicare doesn’t cover and pay as a secondary payer for those things Medicare does cover. Sometimes those plans pay fhe full Part B deductible and 20% Part B coinsurance and sometimes they pay a percentage of the 20%.

Here is a booklet you may want to read that explains how Medicare pays for dialysis and transplant:

Medicare Coverage of Kidney Dialysis and Kidney Transplant Services