Let’s Learn Medicare Medicare for People with End-Stage Renal Disease (ESRD)

© 2015 Medicare Rights Center 2 Medicare Rights Center  The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through: Counseling and advocacy Educational programs Public policy initiatives

© 2015 Medicare Rights Center 3 National Council on Aging  This toolkit for State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs), and Aging and Disability Resource Centers (ADRCs) was made possible by grant funding from the National Council on Aging

© 2015 Medicare Rights Center 4 This training will cover  Medicare eligibility and enrollment for people with End-Stage Renal Disease (ESRD)  Medicare coverage of ESRD treatment  Other types of insurance and ESRD Medicare The 30-month coordination period  Coverage of immunosuppressant drugs after a kidney transplant  Medigaps, Medicare Advantage plans, and Part D enrollment for people with ESRD  ESRD and the Health Insurance Marketplaces Note: If you have ESRD Medicare, enrollment and coordination of benefits rules are different than the rules for age- or disability-related Medicare. ESRD Medicare covers ESRD treatments as well as any other medically necessary treatment.

© 2015 Medicare Rights Center 5 Parts of Medicare  Medicare benefits administered in three parts: Part A – Hospital/Inpatient Benefits Part B – Doctors/Outpatient Benefits Part D – Prescription Drug Benefit  What happened to Part C?  Medicare Advantage Plans (e.g., HMO, PPO) Way to get Parts A, B, and D through one private plan Administered by a private insurance company Not a separate benefit: everyone with Medicare Advantage still has Medicare

© 2015 Medicare Rights Center 6 Medicare Eligibility and Enrollment for People with ESRD

© 2015 Medicare Rights Center 7 Medicare eligibility based on ESRD  You are eligible for Medicare if: You have End-Stage Renal Disease (ESRD)  Permanent kidney failure that requires dialysis or a kidney transplant You, your spouse, or your parent has enough Medicare work history to qualify for Social Security benefits  Note: you do not have to be 65 years old to qualify for ESRD Medicare

© 2015 Medicare Rights Center 8 When Medicare begins with ESRD  Medicare benefits begin depending on how you receive your ESRD treatment: Dialysis at a facilityHome dialysisKidney transplant Medicare begins after a three-month waiting period while receiving dialysis Coverage begins on the first day of the fourth month of dialysis Waiting period starts even if you do not sign up for Medicare No waiting period Medicare begins the same month as the home dialysis training program You must be able to finish the training program and continue home dialysis after it ends No waiting period Medicare begins the month you go into a Medicare- approved hospital for transplant or the services needed before transplant—as long as you get transplant over the following two months

© 2015 Medicare Rights Center 9 End of Medicare coverage for ESRD  If you have Medicare only because of ESRD, Medicare coverage ends: 12 months after the month you stop dialysis treatments or 36 months after the month of a successful kidney transplant  If you have ESRD Medicare and then enroll in Medicare based on age or disability, your Medicare coverage will continue  Note: If you had ESRD Medicare and it ended, Medicare coverage starts again without a waiting period if you begin dialysis again or get another kidney transplant

© 2015 Medicare Rights Center 10 How to enroll in ESRD Medicare  If you are eligible for ESRD Medicare, call Social Security ( ) or visit your local Social Security office to enroll  A family member or other responsible party can also enroll for you if you are unable to do so  Dialysis facility must complete and send a form to the Social Security Administration to confirm ESRD status and the type of treatment needed

© 2015 Medicare Rights Center 11 Medicare coverage of ESRD treatment Medicare covers:  Kidney transplants  Immunosuppressant drugs after a Medicare-covered kidney transplant As long as you still qualify for Medicare and has Part B  Inpatient and outpatient dialysis  Home dialysis training, equipment, supplies, and medications Medication is only covered when overseen by a physician Note: Medicare covers all ESRD treatments the same way, regardless of whether you have ESRD Medicare or Medicare due to age or disability.

© 2015 Medicare Rights Center 12 Medicare and Other Types of Insurance for People with ESRD

© 2015 Medicare Rights Center 13 Employer insurance and Medicare  For people with ESRD Medicare, employer insurance can be any combination of: Active employer coverage from you or your spouse Retiree insurance Union coverage COBRA  Employer coverage is primary to ESRD Medicare only for the first 30 months that you qualify for ESRD Medicare This is called the 30-month coordination period Remember: Coordination of benefits works differently for ESRD Medicare than for Medicare based on age or disability, but Medicare covers medical care for ESRD the same way as it covers care for people with Medicare due to age or disability.

© 2015 Medicare Rights Center 14 The 30-month coordination period During 30-month coordination period Coordination period begins the month you become eligible for Medicare Your employer insurance pays primary to Medicare during this time You do not have to enroll in Medicare if you have other coverage After 30-month coordination period Medicare becomes your primary payer This change happens automatically; after 30-month coordination period ends, Medicare automatically becomes your primary insurance This is why it is important to enroll in Medicare before the 30- month coordination period ends You have until end of 30-month coordination period to enroll in Medicare

© 2015 Medicare Rights Center 15 Taking ESRD Medicare  If you have employer coverage, it may still be best to enroll in ESRD Medicare when you first qualify to help pay costs associated with care Remember, if you have enrolled in Medicare, it pays second during the 30-month coordination period  Talk to your employer before taking or delaying ESRD Medicare Ask how costs will compare if you have employer coverage alone versus employer coverage and Medicare

© 2015 Medicare Rights Center 16 Delaying ESRD Medicare  If you delay ESRD Medicare enrollment: Delay both Part A and Part B  If you delay both Parts A and B, you can enroll in both at any time while you still have ESRD  If you enroll in Part A and decline Part B, you may have gaps in coverage and higher costs Only allowed to enroll in Part B during certain times of year Premium penalty applies for each 12-month period of delayed enrollment  To prevent gaps in coverage, apply for ESRD Medicare Parts A and B at least a few months before your 30- month coordination period ends

© 2015 Medicare Rights Center 17 Medigaps, Medicare Advantage, and Part D for People with ESRD

© 2015 Medicare Rights Center 18 Medigap policies for people with ESRD  Medigap policies (Medigaps) pay the cost-sharing associated with Original Medicare  If you have ESRD Medicare, you may not be able to purchase a Medigap  Federal law does not require Medigap insurers to sell Medigaps to people with ESRD who are under age 65 States may have additional protections that allow someone with ESRD to purchase a Medigap policy Contact your State Health Insurance Assistance Program (SHIP) or Area Agency on Aging (AAA) for more information To find your SHIP or AAA, call

© 2015 Medicare Rights Center 19 ESRD and Medicare Advantage plans  Most people with ESRD cannot join a Medicare Advantage plan There are some exceptions to this rule To find out the exceptions, contact your State Health Insurance Assistance Program (SHIP) or Area Agency on Aging (AAA) To find your SHIP or AAA, call  If you develop ESRD after joining a Medicare Advantage plan, the plan cannot disenroll you

© 2015 Medicare Rights Center 20 Enrolling in a Part D plan with ESRD  If you have ESRD Medicare, enroll in Part D as you would with any other type of Medicare eligibility  Talk to your employer to see how Medicare Part D would coordinate with your coverage  People with employer coverage may not need Part D You can delay Part D without penalty if you have creditable coverage and join a Part D plan within 63 days of losing coverage Before joining a Part D plan, make sure it will not cause employer coverage to end  If you do not have employer coverage, enroll in Medicare Part D to help cover drug costs

© 2015 Medicare Rights Center 21 ESRD and low-income programs  If you have ESRD Medicare, you can qualify for low- income programs to help with Medicare costs, such as: Medicare Savings Programs (MSPs) Extra Help Medicaid  Contact your State Health Insurance Assistance Program (SHIP) or Area Agency on Aging (AAA) for more information on programs that can help you afford Medicare costs To find your SHIP or AAA, call

© 2015 Medicare Rights Center 22 Medicare Coverage of Immunosuppressant Drugs

© 2015 Medicare Rights Center 23 Medicare coverage of immunosuppressants  After a kidney transplant, you will need to take immunosuppressant drugs for the rest of your life to prevent your body from rejecting the new kidney  Normally, immunosuppressants are covered under Part A at the time of a Medicare-covered transplant  After you leave the hospital, Part B covers immunosuppressant drugs if you had Part A at the time of the transplant, so long as you continue to have Part B  If you did not have Medicare when you had a transplant, there are two ways to get coverage: Enroll retroactively in Part A if it is within a year of your transplant; or Get coverage under your Part D plan if you do not qualify for Part B coverage of your drugs

© 2015 Medicare Rights Center 24 Part D coverage of ESRD-related drugs  Part D plans must cover your immunosuppressant drugs if you do not qualify for Part B coverage for them All Part D formularies must include most immunosuppressant drugs  Check to make sure your drugs are covered with the fewest restrictions and that your plan includes your pharmacy as a preferred network pharmacy

© 2015 Medicare Rights Center 25 ESRD and the Health Insurance Marketplaces

© 2015 Medicare Rights Center 26 Health Insurance Marketplaces  Part of the Affordable Care Act (ACA) Also known as Obamacare  A way for people to shop for health insurance coverage  Also called Exchange or Insurance Exchange  Insurance purchased through the Marketplace = Qualified Health Plan (QHP) QHPs purchased through the Small Business Health Options Program (SHOP) = SHOP plans QHPs purchased by individuals through the Marketplace = QHPs

© 2015 Medicare Rights Center 27 ESRD and the Marketplaces  SHOP plans work with ESRD Medicare the same way that other employer coverage does Must follow the 30-month coordination period  If you have any part of Medicare already, you cannot purchase a QHP for individuals  Two groups of people with ESRD may want to consider an individual QHP instead of or in addition to Medicare (assuming not already enrolled in Medicare, in which case a QHP is not allowed): You have a QHP when you develop ESRD You are uninsured and have ESRD  You should compare the costs and coverage of these options before making a decision

© 2015 Medicare Rights Center 28 ESRD and the Marketplaces  When comparing costs, consider: Most people with Medicare are not eligible for tax credits to purchase QHPs People with ESRD are eligible for tax credits if they have not yet enrolled in any part of Medicare  If you decide to forego ESRD Medicare and enroll in a QHP, get written confirmation from your QHP that it will provide primary coverage  If you are considering a QHP instead of or in addition to Medicare, compare QHP costs and coverage against your own needs  When you turn 65 or become eligible for Medicare due to a disability, you should enroll in Medicare

© 2015 Medicare Rights Center 29 For more information and help  Local State Health Insurance Assistance Program (SHIP)  Social Security Administration  Medicare 800-MEDICARE ( )  Medicare Rights Center  National Council on Aging

© 2015 Medicare Rights Center Medicare Interactive  Medicare Interactive  Web-based compendium developed by Medicare Rights to be used as a counseling tool to help people with Medicare Easy to navigate Clear, simple language Answers to Medicare questions and questions about related topics, for example: “How do I choose between a Medicare private health plan (HMO, PPO or PFFS) and Original Medicare?” 1.5 million annual visits and growing 30