Medicare for People with End-Stage Renal Disease and Disabilities Module 6 * Lesson A - Medicare for People with End-Stage Renal Disease (ESRD) * Lesson B - Medicare for People with a Disability Lesson A - Medicare for People with End-Stage Renal Disease (ESRD) * Overview * Eligibility and enrollment * Coverage * Health plan options * Information sources 5 Stages of Chronic Kidney Disease Medicare for People with End-Stage Renal Disease (ESRD) * ESRD is irreversible and permanent kidney failure - Stage V chronic kidney disease - Requires a regular course of dialysis or - Kidney transplant to sustain and improve quality of life * Medicare coverage based on ESRD began in 1973 * Over 443,700 were enrolled during 2008 * More than 1 million Americans treated since 1973 Medicare Education Benefit - Stage IV * Medicare covers kidney disease education services - If you already have Medicare (e.g., 65 or older) - Have Stage IV chronic kidney disease - Advanced kidney damage - Covers up to six sessions if referred by your doctor - Covered by Medicare Part B - Provided to help delay the need for dialysis or transplant Eligibility for Part A Based on ESRD at Any Age if… * You get a regular course of dialysis or had a kidney transplant AND - Worked required time under Social Security, the Railroad Retirement Board (RRB), or as a government employee; or - Are getting or are eligible for Social Security, railroad retirement, or Federal retirement benefits; or - Are the spouse or dependent child of a person who meets requirements above Part B Eligibility * Can enroll in Part B if entitled to Part A - You may pay Part B penalty if you delay enrollment * Part A and Part B for complete coverage * For more information - Call Social Security at 1-800-772-1213 - Call RRB at 1-877-772-5772 Part D Eligibility * Medicare prescription drug coverage - Available for all people with Medicare - Must enroll in a plan to get coverage - You pay a monthly premium and a share of Rx costs - Extra help for people with limited income and resources When Coverage Ends * If ESRD is the ONLY reason you were entitled - 12 months after month you no longer require a regular course of dialysis or - 36 months after month of kidney transplant When Coverage Continues * No interruption in coverage - Within 12 months after stopping a regular course of dialysis * If a regular course of dialysis is resumed or you have a kidney transplant - Within 36 months after a kidney transplant * If a regular course of dialysis starts or you need another kidney transplant When Coverage Resumes * More than 12 months after dialysis ends - A regular course of dialysis is resumed or you have a kidney transplant * More than 36 months after kidney transplant - A regular course of dialysis starts or another kidney transplant * Must file new application * No waiting period Enrolling in Part A and Part B * Enroll at local Social Security office - Doctor or dialysis facility needs to fill out Form CMS-2728 * May want to delay enrolling if covered by group health plan (GHP) or employer group health plan (EGHP) * Get the facts before deciding to delay - Especially if transplant is planned Enrolling in Part B * Enroll in Part A and delay enrolling in Part B - Must wait for General Enrollment Period * January 1 through March 31 each year, coverage begins July 1 - May have to pay higher premium as long as you have Part B * 10% for each 12-month period eligible but not enrolled * No Special Enrollment Period Enrolling in Part B * Have Medicare due to age or disability - ESRD enrollment may eliminate Part B penalty * Medicare due to ESRD and reach age 65 - Have continuous coverage - Those not enrolled in Part B * Will be enrolled in Part B with no penalty and may decline - Those enrolled in Part B and paying a penalty * Penalty will be removed Medicare and GHP Coverage * If ESRD is only reason you have Medicare - During first 3 months of a regular course of dialysis GHP/employer is only payer * Medicare is secondary payer for 30-month coordination period - Begins when first eligible for Medicare even if not enrolled - New 30-month period begins if new period of Medicare coverage 30-Month Coordination Period * During coordination period - GHP pays first - Medicare pays second * Medicare pays first after 30 months Enrollment Considerations * Medicare during 30-month coordination period - May not need Medicare - Could help pay deductibles and coinsurance - Higher premium if delay Part B - Possible higher premium if delay Part D - Affects coverage for immunosuppressive drugs Enrollment Considerations * Immunosuppressive Drugs - Covered by Part B as long as you have Medicare * If entitled to Part A at time of transplant and * Medicare paid for the transplant or * Medicare was secondary payer but made no payment - Part D may cover if transplant conditions not met Enrollment Considerations * Immunosuppressive drugs - Covered under Part B - Medicare pays 80% and you pay 20% - Part D coverage only if Part B coverage conditions not met * Helps pay for drugs needed for other conditions * Extra help for people with limited income and resources Let's look at a case study… * Brad is 59 and is entitled to Medicare based on ESRD. He began a regular course of dialysis 3 months ago, so he believes his Medicare coverage will begin in his fourth month of a regular course of dialysis. - Is he correct? - Are there situations when it would begin earlier? Covered Benefits * All services covered by Original Medicare - Medicare Part A - Medicare Part B * Special services for - Dialysis and transplant patients * Including immunosuppressive drugs under certain conditions Covered Dialysis Services * Inpatient dialysis treatments * Facility dialysis treatments * Home dialysis training * Self-dialysis training * Home dialysis equipment & supplies * Some support services & drugs for home dialysis Home Dialysis * Both hemodialysis & peritoneal dialysis * Most common drugs covered by Medicare - Heparin to slow blood clotting - Drug to help clotting when necessary - Topical anesthetics - Epoetin alfa for anemia management Services NOT Covered Under Part B * Paid dialysis aides * Lost pay * Place to stay during your treatment * Blood for home dialysis (some exceptions) * Transportation to dialysis facility except special cases * Non-treatment related medicines Medicare Part A Transplant Patient Coverage * Inpatient services ― Medicare-approved transplant center * Transplant (living or cadaver donor) ― Full cost of care for a living donor * Preparation for transplant * Kidney Registry fee * Laboratory tests Medicare Part B * Coverage for transplant patients - Surgeon's services - Doctor's services to donor * No deductible - Immunosuppressive drug therapy * Under certain conditions Let's look at a case study… * Jeff is 48 years old and just applied for Medicare based on ESRD. He knows he will probably need a kidney transplant in the near future. What does he need to know, especially about immuno-suppressive drug therapy coverage under Part B? Part D? ESRD and Medicare Advantage (MA) Plans * Usually can't join an MA Plan if you have ESRD - Exception for those who have had a kidney transplant - You may be able to join a MA Plan * If your EHG plan is same organization offering the MA Plan * MA plan is primary provider of your health care coverage - May be able to join a Medicare Special Needs Plan Special Needs Plans (SNPs) * Limit membership to certain groups of people * Some SNPs serve people with ESRD and provide - Special provider expertise - Focused care management * Available in limited areas * Must provide prescription drug coverage ESRD and Medicare Advantage Plans * If already in MA Plan may stay in plan - Can join another plan from same company in same state - Can join another plan if plan leaves * May be able to join after kidney transplant * If in non-Medicare plan can join MA Plan from same company - Must be no break in coverage Let's look at a case study… * Rachel is 43 years old and was diagnosed with ESRD 8 months ago. She has looked at some marketing materials from a Medicare HMO Plan and would like to join. - Can she join? - Discuss the situations where she would be able to join - Might she have another option? * Contact your local ESRD Network for help with - Dialysis or kidney transplants - How to get help from other kidney-related agencies - Problems with your facility that aren't solved after talking to the facility staff - Locating dialysis facilities and transplant centers * National Vascular Access Improvement Initiative - To increase use of fistulas for hemodialysis - Surgical connections joining a vein and an artery in the forearm - Provides access for dialysis - Improved outcomes ESRD Information Sources * 1-800-MEDICARE * State Health Insurance Assistance Programs * End-Stage Renal Disease (ESRD) Network - Local telephone numbers on www.medicare.gov * American Association of Kidney Patients - 1-800-749-2257, www.aakp.org * National Kidney Foundation - 1-800-622-9010, www.kidney.org * American Kidney Fund - 1-800-638-8299, www.kidneyfund.org * United Network for Organ Sharing - 1-888-894-6361, www.unos.org Medicare ESRD Publications * Medicare Coverage of Kidney Dialysis and Kidney Transplant Services, CMS Pub. #10128 * Dialysis Facility Compare Tool at www.medicare.gov, CMS Pub. # 10208) * Preparing for Emergencies: A Guide for People on Dialysis, CMS Pub. # 10150 * You Can Live - Your Guide to Living with Kidney Failure, CMS Pub. # 02119 * Medicare for Children with End-Stage Renal Disease, CMS Pub. # 11392 Dialysis Facility Compare www.medicare.gov/Dialysis * Searchable database - Facility locations - Treatments - Ownership - Night services - Quality measures * Percent of patients adequately dialyzed * Percent whose anemia is adequately managed * Patient survival information Exercise A. Which is true about End-Stage-Renal Disease? Exercise B. Coverage based on ESRD Lesson B - Medicare for People with a Disability * Overview of Medicare for people with a disability * Eligibility and enrollment * Medicare plan options * Medigap * Information sources Medicare and Social Security * Medicare is title XVIII of the Social Security Act - Usually based on entitlement to Social Security benefits * 1972 amendments expanded Medicare - Under age 65 entitled to Social Security disability benefits for 24 months - With End-Stage Renal Disease (ESRD) * Don't need to be receiving Social Security benefits Social Security Programs * Retirement, Survivors and Disability Insurance - Based on covered earnings and funded by FICA * Supplemental Security Income (SSI) - Based on need and funded by general revenues * Both pay benefits for people with disabilities - But SSI does not qualify people for Medicare * Many qualify under both programs Disability Defined * Inability to work - Expected to last for at least 1 year or result in death - Can be the result of blindness * Visual acuity 20/200 or less with correcting lens in better eye or * Visual field of 20 degrees or less Qualifying for Disability Benefits * Must meet definition of disability * Must have earned enough work credits - Or are the spouse of someone with work credits - Or are the dependent child of someone with work credits * 5-month waiting period - Except people eligible for childhood disability benefits or - Some people previously entitled to disability benefits Applying for Disability Benefits * When you apply, take your - Social Security Number - Proof of age - Health-care provider information - Medical records - Work history, including W-2 * Don't wait to apply Qualifying for Medicare * Most people have a 24-month waiting period * Usually begins 30th month after disability began - 5 months + 24 months = 29-month wait * Exception for people with ALS - No additional waiting period - Medicare starts with first month of disability benefits Automatically Enrolled in Original Medicare * Will receive card by mail - Most people - after 24 months of disability entitlement - Those with ALS - about 4 weeks after Medicare entitlement - Call Social Security if Medicare card doesn't arrive - Decide whether to keep or decline Part B - Decide whether to enroll in Part D Continuation of Medicare Entitlement * Continues if you are working but still disabled - 8½ years premium-free Part A - May purchase coverage afterward * Ends when SSA decides you're no longer disabled * Entitlement reason changes at age 65 Plan Choices for People with a Disability * All Medicare plans available - Original Medicare * Medigap policy (supplements Original Medicare) - Medicare Advantage Plans - Other Medicare plans - Medicare Prescription Drug Plans - Exception for those with ESRD Exercise A. Most people who receive Social Security cash benefits because of a disability are eligible for Medicare: Exercise B. Medicare health plan choices available to people with disabilities include: If You Want to Know More… * Social Security 1-800-772-1213 - TTY users call 1-800-325-0778 * 1-800-MEDICARE (1-800-633-4227) - TTY users call 1-877-486-2048 * U.S. Railroad Retirement Board, www.rrb.gov * State Health Insurance Assistance Program (SHIP) * State Office on Aging * Web - www.socialsecurity.gov - www.medicare.gov - www.cms.gov