Health Insurance 101: Options for People with ESRD

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on June 12th, 2015.
Health Insurance 101: Options for People with ESRD

Dialysis clinic staff are often called upon to help people make choices about how to pay for their treatment. Kidney disease is costly, but for US citizens and those in the US legally, there are multiple payment options. People with kidney disease must look for a plan that will cover hospital stays, doctors and other providers, dialysis (including home dialysis) and transplant (including living donors), supplies and equipment, and drugs. They need to plan for changes as they move from kidney damage to kidney failure, and to or from dialysis or transplant. And, there may be different things to weigh with a health plan sponsored by an employer or union.

The table below addresses some common questions and compares Original Medicare, Medicare Advantage, and health insurance marketplace plans set up under the Affordable Care Act (ACA, or “Obamacare”).

Question Original Medicare Medicare Advantage (MA) Health Insurance Marketplace
WHO is eligible?
  • Citizen or legally present for >5 years
  • Have ESRD (dialysis or transplant)
  • Citizen or legally present in US >5 years
  • Live in plan’s area
  • Once on dialysis: can enroll only in one of the few Special Needs Plans (SNPs) accepting ESRD
  • With a transplant: can enroll in any MA plan
  • Citizen or legally present and not incarcerated
  • Can’t join if Medicare Part A and/or Part B, full Medicaid or CHIP are in effect
  • Can keep after enrolling in Medicare, but lose tax credits
WHEN can a person with ESRD enroll?
  • Initial Enrollment Period (IEP): 3 mo. before eligible mo. through 3 mo. after eligible mo.
  • General Enroll-ment Period (GEP): If Part A was taken alone at first, can only apply for Part B Jan. 1-March 31 each year & Part B takes effect the next July 1st
  • Dialysis patients are NOT eligible for a Special Enrollment Period (SEP) to enroll late in Part B after taking Part A so must wait for the GEP.
  • Initial Coverage Enrollment Period: same as Original Medicare
  • Open Enrollment Period: Join or switch health/drug plans each year from Oct. 15-Dec. 7 for a plan that starts on Jan. 1
  • MA Disenrollment Period: switch from an MA plan to Original Medicare & enroll in a Part D plan Jan. 1-Feb. 14; before switching, have a plan to pay Original Medicare deductibles & copays (options in left column).
  • For 2016: Nov. 1, 2015-Jan 31, 2016
  • Special Enrollment: If status changes or other coverage is lost
WHAT happens if a person is late to enroll?
  • For failure to enroll in Part B after taking Part A during the IEP, the Part B premium penalty is 10% per year of delay
  • N/A: MA plans include Part A & B automatic-ally—but not all include Part D (if not, buy a Part D plan)
  • May keep marketplace plan
  • If fail to enroll in Medicare during the IEP, there is a 10% penalty each year of delay for Part B & premium Part A
WHEN will the plan take effect?
  • There is a 3 month wait for Part A & B unless someone starts home training or gets a transplant during those 3 months. Then Medicare backdates to the 1st month of dialysis or pre-emptive transplant.
  • Same as Original Medicare
  • Apply Nov. 1 – Dec. 31, & plan starts Jan. 1
  • Apply Jan. 1-31 & plan starts Feb. 1
  • With a special enrollment period, coverage starts the month after enrollment
What are the TYPES of coverage?
  • Part A: Hospital (inpatient, rehab, skilled nursing, hospice, recipient & donor’s transplant surgery, etc.)
  • Part B: Medical (outpatient, doctors, dialysis, some dialysis-related drugs & anti-rejection drugs)
  • No coverage for most dental, vision, hearing
  • Providers that accept Medicare assignment cannot balance bill those with Medicare for charges more than 100% of what Medicare allows
  • Structure: HMOs, PPOs, Private Fee for Service, Special Needs Plans, HMO Point of Service, Medical Savings Accounts
  • Includes Parts A & B, and may cover drugs on formulary, vision, dental, hearing
  • Network may be more limited than Original Medicare
  • Structure: Bronze, Silver, Gold, Platinum “metal plans” & a Catastrophic plan for <30 year olds & those who have a hardship exemption
What is the PREMIUM in 2015?
  • Part A: Free with enough work credits; if 65 & few/ no credits, the cost is up to $407/mo.
  • Part B: $104.90/mo, or more if income is $80K single/$160K couple
  • State may pay A&B premiums if someone qualifies for Medicare savings program
  • Varies with plan. Plans with lower premiums may have higher out-of pocket costs
  • Varies with plan. Plans with lower premiums may have higher out-of pocket costs
What are other possible OUT-OF-POCKET COSTS in 2015?
  • Part A deductible:
  • Deductible: $1,260 for hospital days 1-60
  • Copay days 61-90: $315 per day
  • Get back days 1-90 if out of hospital 60 days
  • Copay days 91-150 (lifetime re-serve): $630/day
  • Once lifetime reserve days are used, they’re gone
  • Part B
  • Deductible: $147/year
  • Coinsurance: 20% of allowed charge (with no maximum)
  • Up to $6,700/year for an individual for Part A and B covered benefits
  • Up to $6,600/year for an individual plan or $13,200/year for a family plan
  • Bronze: pays average of 60%;
  • Silver: pays average of 70%
  • Gold: pays average of 80%
  • Platinum: pays average of 90%
  • Catastrophic: pays average of <60% of cost of care for <30 years old or those with a hardship exemption
HOW can out-of-pocket costs be paid?
  • Medigap plans pay all or most out-of-pocket costs for Medicare-covered services; some states have no Medigap plans for those <65 or with ESRD
  • Medicaid: Medicare out-of pocket costs, if qualify
  • Medicare savings programs pay premiums, may pay copays & coinsurance if qualify
  • Other health insurance plan: employer or union health plan, private plan off the marketplace
  • Medicaid if eligible
  • Cannot use Medigap
  • There are Special Needs Plans (SNPs) for those with both Medicare & Medicaid
  • In states that expanded Medicaid: those with incomes ≤138% of federal poverty could get help to pay MA plan share of costs
  • Income of 100-400% of the federal poverty level may qualify for a premium tax credit (Silver plan)
  • Income of 100-250% of the federal poverty level may qualify for lower out-of-pocket costs (Silver plan)
  • No savings if income is <100% of federal poverty
  • NOTE: In a state that expanded Medicaid, those with incomes ≤138% can stay in plan OR have Medicaid. Medicaid may cost less—but may also limit providers.
What are the options for DRUG coverage?
  • Part B covers some drugs, including anti-rejection IF Part A was in effect the transplant month
  • Private companies sell Part D plans; formulary used & costs vary
  • State Pharmacy Assistance Programs (where offered) can help
  • State kidney programs (if available) may help
  • Drugs may be part of MA plans
  • If no drug coverage, may buy a Part D plan; formulary & costs vary
  • State Pharmacy Assistance Programs (where offered) may handle MA drug plan coordination differently than Original Medicare
  • Drugs are included in the basic benefit
  • Formulary & costs vary
  • A transplant recipient may want to keep this plan since Medicare ends 36 months post-transplant. Part B will never cover anti-rejection drugs if Part A was not in effect the month of transplant.
WHEN is drug plan enrollment?
  • Initial Enrollment Period (IEP) is the same as the 7 mo. Part B IEP. But, if Medicare is back-dated, IEP start is based on the Medi-care award letter date.
  • Yearly: Oct.15-Dec. 7
  • Medicaid, those receiving “extra help” due to limited income or in nursing homes can switch any time. The new plan starts the next month.
  • Initial Enrollment Period (IEP) is the same as the 7 mo. Part B IEP.
  • Special Enrollment Period: when a person switches from Original Medicare to MA, from MA to Original Medicare, or from one MA plan to another
  • No separate enrollment; drug coverage is included in individual marketplace and SHOP plans
  • Drug coverage may not be as good as Medicare Part D. Each year, the plan must tell members whether the drug plan pays as well as Part D
How do benefits COORDINATE WITH employer or union plans?
  • Can have Original Medicare with a union/employer plan
  • Employer plan pays 1st for 30 months from 1st mo. eligible for Medi-care. Providers who take Medicare must write off charges over Medicare’s allowed charge.
  • After 30 months, Medicare pays 1st and union/ employ-yer plans pay 2nd. As a secondary payer, union/em-ployer plans may have out-of-pocket costs.
  • May be able to have both. Have the person ask the employer or union if joining an MA plan risks that coverage for him/her and any dependents. It may.
  • Someone who gives up an employer or union plan may not get it back
  • Employers with ≤50 full-time employees may provide a marketplace plan & dental plan through Small Business Health Options Program (SHOP)
  • If someone has Medicare & a SHOP plan, payment follows Medicare secondary payer rules like Original Medicare
  • No penalty for late enrollment in Part B (or premium Part A) for those in SHOP plans
How does a patient’s WORK affect plan
  • People on dialysis can work & keep Medicare (see section on coordin-ation of benefits)
  • Employer plans pay first for transplant recipient on Medicare due to disability after ESRD benefit ends at 36 mo. post-transplant if plan is based on own or family’s current work & employer has ≥100 employees
  • Employer plans pay first for transplant recipients on Medicare due to age after ESRD benefit ends at 36 mo. post-transplant if plan is based on own or family’s current work & employer has ≥20 employees
  • People on dialysis can work & keep Medicare (see section on coordin-ation of benefits)
  • Employer plans pay first for transplant recipi-ents on Medicare due to disability after ESRD benefit ends at 36 mo. post-transplant if plan is based on own or family’s current work & employer has ≥100 employees
  • Employer plan pays first for transplant recipi-ents on Medicare due to age after ESRD benefit ends at 36 mo. post-transplant if plan is based on own or family’s current work & employer has ≥20 employees
  • If eligible for an employer plan that costs <9.56% of income & covers at least 60% of costs, an individual may choose a marketplace plan—but may not get income-based savings & employer may not contribute to premium
How LONG will the plan last?
  • ≥65: as long as premiums are paid
  • On dialysis: as long as dialysis continues
  • Kidney function improves (so dialysis or transplant are not needed): 12 months
  • Medicare is due to disability: as long as disability lasts and premiums are paid
  • ESRD is the only reason for Medicare: as long as on dialysis (even if working), but ends 36 mo. after transplant
  • Transplant on SSDI: If SSDI ends before 36 months after transplant, arrange how to pay the Medicare premium to avoid losing it
  • On dialysis: as long as dialysis continues
  • Kidney function improves (so dialysis or transplant are not needed): 12 months
  • Medicare is due to disability: as long as disability lasts and premiums are paid
  • ESRD is the only reason for Medicare: as long as on dialysis (even if working.) but ends 36 mo. after transplant
  • Transplant on SSDI: If SSDI ends before 36 months after transplant, arrange how to pay the Medicare premium to avoid losing it
  • As long as the premium is paid or the person cancels the plan
  • Can switch plans during open enrollment annually

Helpful Resources:

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Comments

  • laurel Hoffman

    Dec 10, 11:12 AM

    Hi, A pt has part A. He did not sign up for part B. Now he is ESRD on dialysis and needs Part B ASAP. He was told he can apply through SS for Part B to take effect immediately based on first date of dialysis according to his 2728. Is this correct?

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    • Beth Witten

      Dec 10, 12:49 PM

      Being diagnosed with ESRD provides a new 7-month "initial enrollment period" for Medicare Part B. I would suggest the patient talk with Social Security and apply for Part B to start the first month he's eligible for Medicare due to ESRD. He will need to pay Part B premium for those months. He should ask Social Security about his premium payment options.

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  • Swagata Pandit

    Jul 6, 8:51 AM

    This is a very well written and useful article.

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  • ruth

    Jun 15, 11:46 AM

    this is Superific!!

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  • Cindy Paris

    Jun 15, 10:48 AM

    Does anyone know where you can get a secondary insurance for residences of Idaho State?

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    • Beth Witten

      Jul 8, 9:29 PM

      Unless something has changed recently, state regulations in Idaho do not require health insurers that sell Medigap plans to those 65 and older with Medicare to sell Medigap plans to those under 65 who have Medicare. You might want to look at this site under Options for Under 65 on Medicare. http://www.doi.idaho.gov/shiba/shibahealth.aspx

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