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1 2004 REACH National Medicare Training Program. 2 Medicare Entitlement Because of ESRD or Disability Module 6.

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Presentation on theme: "1 2004 REACH National Medicare Training Program. 2 Medicare Entitlement Because of ESRD or Disability Module 6."— Presentation transcript:

1 REACH National Medicare Training Program

2 2 Medicare Entitlement Because of ESRD or Disability Module 6

3 3 Medicare for People with End-Stage Renal Disease Module 6 Lesson A

4 4 Session Topics Overview Eligibility and enrollment Coverage Health plan options Information sources

5 5 Session Topics Overview Eligibility and enrollment Coverage Health plan options Information sources

6 6 End-Stage Renal Disease Often referred to as ESRD Kidney impairment –Appears irreversible and permanent –Requires regular dialysis or a kidney transplant to maintain life Overview

7 7 Medicare for People with ESRD Coverage began in 1973 Over 1 million received life-saving therapy –Dialysis –Transplant Over 350,000 receiving therapy 90,000 had successful kidney transplant 20,000 improved so much they left Medicare Overview

8 8 Session Topics Overview Eligibility and enrollment Coverage Health plan options Information sources

9 9 Part A Eligibility Requirements Eligible for Medicare Part A at any age if –Regular dialysis or –Kidney transplant AND at least one of the following –Worked required amount of time –Receiving SSA or RRB cash benefits –Spouse or dependent child of someone who worked required amount of time Eligibility and Enrollment

10 10 Part B Eligibility If entitled to Medicare Part A –Can enroll in Part B Will have to pay Part B premium Will need both Part A and Part B to cover certain services For more information –Call SSA at –Call RRB at Eligibility and Enrollment

11 11 Enrollment Enroll at local SSA office May delay enrollment if covered by GHP Get the facts before deciding to delay –Especially if transplant is planned If already enrolled in Part A –May eliminate Part B surcharge Eligibility and Enrollment

12 12 30-Month Coordination Period During coordination period –GHP pays first –Medicare pays second Begins when eligibility or entitlement begins –Even if not enrolled in Medicare Medicare pays first after 30 months New 30-month period begins if new period of Medicare coverage Eligibility and Enrollment

13 13 Enrollment Decision Can delay enrollment in Medicare (Part A and Part B) Considerations in delaying –Medicare could help pay deductibles and coinsurance –No Part B premium if you delay enrollment –Immunosuppressive drug therapy is covered If you were entitled to Part A at time of transplant and Medicare made payment for transplant OR If Medicare made no payment, Medicare was secondary payer, AND you are enrolled in Part B at time of drug therapy For as long as you have Medicare Eligibility and Enrollment

14 14 ESRD Coverage Begins Third month after the month dialysis begins First month if certain conditions are met Month you receive a kidney transplant Month you are admitted to approved hospital –For transplant or procedures preliminary to transplant 2 months before month of transplant –If transplant is delayed more than 2 months Eligibility and Enrollment

15 15 Coverage Ends If ESRD is the ONLY reason you were entitled 12 months after month you no longer require maintenance dialysis OR 36 months after month of kidney transplant Eligibility and Enrollment

16 16 Coverage Continues or Resumes If dialysis is resumed OR Another transplant is received Eligibility and Enrollment

17 17 Let’s see what we know… Your 30-month coordination period begins when your eligibility or entitlement begins, even if you are not enrolled in Medicare. True or False?

18 18 Here is a case study… Brad is 59 and is entitled to Medicare based on ESRD. He began dialysis 3 months ago, so he believes his Medicare coverage will begin in his fourth month of dialysis. Is he correct? Are there situations when it would begin earlier?

19 19 Session Topics Overview Eligibility and enrollment Coverage –Dialysis patients –Transplant patients Health plan options Information sources

20 20 Benefits All services covered by Original Medicare –Medicare Part A –Medicare Part B Special services for –Dialysis patient –Transplant patient Including immunosuppressive drugs –Certain conditions must be met Coverage

21 21 Covered Services Inpatient dialysis treatments Home dialysis training Self-dialysis training Home dialysis equipment and supplies Certain home support services Certain drugs for home dialysis Coverage for Dialysis Patients

22 22 Ambulance Services Transportation to dialysis facility –Covered only if other forms of transportation would be harmful to your health –Ambulance supplier must get written order For information –1-800-MEDICARE ( ) TTY/TDD Coverage for Dialysis Patients

23 23 Home Dialysis Types of dialysis that can be performed at home –Hemodialysis –Peritoneal dialysis Most common drugs covered by Medicare –Heparin –Antidote for heparin when necessary –Topical anesthetics –Epogen® or Epoetin alfa Coverage for Dialysis Patients

24 24 Services NOT Covered Paid dialysis aides Lost pay Place to stay during your treatment Blood for home dialysis –Unless part of doctor’s service or needed to prime the dialysis equipment Transportation to the dialysis facility –Except in special cases Coverage for Dialysis Patients

25 25 Medicare Part A Covers inpatient hospital services for kidney transplant –Transplant –Preparation for transplant –Kidney Registry fee –Laboratory tests –Full cost of care for donor Including care needed due to complications Coverage for Transplant Patients

26 26 Medicare Part B for Kidney Transplant Surgeon’s services Doctor’s services to donor –No deductible Immunosuppressive drug therapy –If entitled to Part A at time of transplant and Medicare paid for transplant OR Medicare made no payment but was secondary payer Coverage for Transplant Patients

27 27 Coverage for Blood Part A and Part B can help pay for –Whole blood –Units of packed red blood cells –Blood components –Cost of blood processing and administration Part A and/or Part B deductible must be met Coverage for Transplant Patients

28 28 Immunosuppressive Drugs Used to reduce the risk of rejection Taken for the rest of your life No time limit if eligible for Medicare because of age or disability Must have Part B at time of dispensing of drug Coverage for Transplant Patients

29 29 Immunosuppressive Drugs If you have Medicare only because of ESRD, Medicare will pay for immunosuppressive drug therapy if –You were entitled to Part A at time of transplant and Medicare paid for the transplant OR If Medicare made no payment, Medicare was secondary payer AND –You are enrolled in Part B at time of drug therapy Coverage for Transplant Patients

30 30 Let’s see what we know… Which service is covered by Medicare? A.Paid dialysis aides B.Lost pay C.Kidney Registry fee

31 31 Let’s look at a case study… Jeff is 48 years old and just applied for Medicare based on ESRD. He knows that he will probably need a kidney transplant in the near future. He decided to apply for Medicare now because he knows that Medicare will pay for his immunosuppressive drug therapy as long as he is covered by Medicare. Is he correct? What are some important points for someone who may be having an organ transplant?

32 32 Session Topics Overview Eligibility and enrollment Coverage Health plan options Information sources

33 33 Original Medicare Usually the only choice Always an option Health Plan Options

34 34 Medicare Advantage Plans Usually not an option for those with ESRD May stay in a plan if already in May be able to join after kidney transplant May join another if your plan leaves May “age in” Health Plan Options

35 35 If Your Plan Leaves Medicare You have options –Can return to the Original Medicare Plan –Can join another Medicare Advantage plan if available in your area If your plan left on or after December 31, 1998 Health Plan Options

36 36 People with Medicare who are entitled because of ESRD can receive both Part A and Part B services. True or False? Let’s see what we know…

37 37 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 Managed Care plan and would like to join. Can she join? Discuss the situations where she would be able to join.

38 38 Session Topics Overview Eligibility and enrollment Coverage Health plan options Information sources

39 39 ESRD Networks Ensure administration of ESRD benefits Develop quality standards Assess treatment modalities Provide technical assistance to dialysis facilities Educate beneficiaries Contact information: Local phone number Information Sources

40 40 ESRD Information Sources American Association of Kidney Patients – National Kidney Foundation – American Kidney Fund – Information Sources

41 41 Dialysis Facility Compare –Searchable database –Facility location –Treatment choices offered –Ownership –Availability of evening services –Quality measures Information Sources

42 42 Quality measures for dialysis facilities –How well facility treats patients –Getting the best possible results Some quality measures –Percent of patients adequately dialyzed –Percent whose anemia is adequately managed –Patient survival information Information Sources

43 43 Key Concepts Most people with ESRD are eligible for Medicare It is important to understand enrollment options People with ESRD receive –All Part A and Part B services –Some additional services Original Medicare Plan is usually only choice More information is available

44 44 Medicare Entitlement Because of a Disability Module 6 Lesson B

45 45 Session Topics Overview Eligibility and enrollment Health plan choices Information sources

46 46 Session Topics Overview Eligibility and enrollment Health plan choices Information sources

47 47 Coverage for Disabled Beneficiaries Coverage began in million beneficiaries initially 5.6 million in 2001 –14% of all Medicare beneficiaries Overview

48 48 Medicare Enrollment Trend Overview

49 49 Social Security and Medicare Relationship between Social Security and Medicare –Medicare is title XVIII of SS Act –Medicare based on entitlement to SS benefits –Amendments expanded Medicare to cover Disabled persons under 65 entitled to SS benefits for 24 months Overview

50 50 Disability Defined Social Security definition –Inability to work –Will last for 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 Overview

51 51 Session Topics Overview Eligibility and enrollment Enrollment process Health plan choices Information sources

52 52 SSA Programs RSDI –Based on covered earnings –Funded by FICA SSI –Based on need –Funded by general revenues Both pay benefits for people with disabilities Eligibility and Enrollment

53 53 Qualifying for Medicare Usually begins after 24 months of benefits Exceptions –Begins first month for ALS –No 5-month waiting period for cash benefits Childhood disability beneficiaries Some people previously entitled to disability benefits Eligibility and Enrollment

54 54 Qualifying for Disability Benefits Meet requirements for SSA disability benefits 5-month waiting period before cash benefits begin Eligibility and Enrollment

55 55 Applying for Disability Benefits Take your –Social Security Number –Proof of age –Medical care provider information –Medical treatment information –Medical records, if available –Work history information –Most recent W-2 or self-employment tax return Eligibility and Enrollment

56 56 Enrollment in Medicare Automatic enrollment in Original Medicare –After 24 months of disability payments Except for ALS –Will receive card by mail Call SSA if it doesn’t arrive –Decide on Part B Eligibility and Enrollment

57 57 Continuing Medicare Entitlement Ends when SSA determines you are no longer disabled Continues for working beneficiaries who are still disabled –8½ years premium-free Part A –May purchase coverage afterward Entitlement reason changes at age 65 Eligibility and Enrollment

58 58 Let’s see what we have learned... Most people who are receiving cash benefits for a disability are eligible for Medicare after 24 months. True or False ?

59 59 Here is a case study… Ramon has been told that he meets the Social Security definition for blindness. He knows he needs to apply for disability benefits, but he does not have all the documents he might need. Should he apply anyway?

60 60 Session Topics Overview Eligibility and enrollment Health plan choices Information sources

61 61 Choices All Medicare plans available –Original Medicare Plan –Medicare Advantage plans Medicare Managed Care plans Private Fee-for-Service plans Some restrictions on eligibility for Medigap Health Plan Choices

62 62 Coverage Coverage same as for people 65 and over All Medicare covered benefits No special limitations Health Plan Choices

63 63 Session Topics Overview Eligibility and enrollment Health plan choices Information sources

64 64 If You Want to Know More… SSA (TTY ) MEDICARE (TTY ) SHIP State Office on Aging Internet –www.ssa.gov –www.medicare.gov –www.cms.hhs.gov Information Sources

65 65 Key Concepts SSA determines disability Eligible for Medicare if you receive cash benefits Receive all benefits Eligible for all health care choices

66 66 Thanks for your attention!

67 67 Medicare Entitlement Because of a Disability Detailed Information

68 68 Supplemental Security Income (SSI) Based on financial need Must be 65 or over, or blind, or disabled –Children may be eligible Benefits reduced for other income Call SSA at for more information

69 69 Social Security Benefits (RSDI) Based on covered earnings Worker and certain family members may qualify –See Social Security Statement for estimates Only certain types of income affect benefits

70 70 Social Security Benefits (RSDI) Retirement benefits for yourself and your –Husband or wife –Dependent children Survivors benefits for your –Widow or widower –Dependent children –Parents Disability benefits for yourself and your –Husband or wife –Dependent children

71 71 Applying for Disability Benefits Apply as soon as you become disabled –1-year limit on retroactive benefits Call or visit any SSA office –TTY number Decision generally takes 60 to 90 days

72 72 Disability Determination Service State agency Determines disability under Social Security law Considers –Medical evidence –Medical report forms –Other information as necessary

73 73 Consultative Examination When the DDS needs more medical information to decide your case Your doctor or medical facility is preferred Social Security pays for the exam and travel expenses May not be a complete examination

74 74 Process for Determining Disability Step-by-step process involving 5 questions –Are you working? –Is your condition “severe”? –Is your condition on list of disabling impairments? –Can you do your previous work? –Can you do any other type of work?

75 75 Disability Decision Sent in a letter If approved, letter shows –Benefit amount –Date payments start If disapproved, letter explains –Reason for denial –How to appeal

76 76 If Claim Is Approved Social Security benefits will be paid –After 5 full months Amount of benefit based on lifetime average earnings Other payments may reduce benefit amount, e.g., Worker’s Compensation Cash benefits may be taxed

77 77 If Claim Is Denied May appeal any part of decision Must appeal within 60 days Social Security provides assistance

78 78 Status of Cash Benefits Case is reviewed periodically –Frequency depends on expectation of recovery Benefits continue based on disability status Cash benefits may stop if: –Earn $810 or more a month –Medical condition improves and no longer disabled

79 79 Termination from Medicare Entitlement to Part A ends –Month of death –Under 65 and no longer disabled –Nonpayment of Part A premiums –Voluntary termination (if buying Part A) –Working, after 8½ years of premium-free Part A Entitlement to Part B ends –Month of death –Month Part A entitlement ends if under age 65 –Nonpayment of Part B premiums –Voluntary termination

80 80 Ticket to Work Provisions 1.Medicare coverage for some disabled working beneficiaries 2.Suspension of Medigap for EGHP 3.State Medicaid options on paying premiums for workers with disabilities

81 81 (1) Extending Medicare Disability Benefits Disabled beneficiaries who return to work and whose earnings are considered substantial ($810 per month in 2004) can receive 8½ years of premium-free Medicare Part A

82 82 (2) Suspending Medigap When Covered by Group Plan Beneficiaries entitled to Medicare because of disability can suspend Medigap while covered under an EGHP Can reinstate Medigap by giving notice of loss of coverage within 90 days

83 83 (3) Expanding State Medicaid Options Working individuals with disabilities have increased opportunities to maintain Medicaid coverage


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