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WHO is eligible?
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- Citizen or legally present for >5 years
- Have ESRD (dialysis or transplant)
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- 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
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- 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
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WHEN can a person with ESRD enroll?
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- 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.
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- 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).
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- For 2016: Nov. 1, 2015-Jan 31, 2016
- Special Enrollment: If status changes or other coverage is lost
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WHAT happens if a person is late to enroll?
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- 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
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- N/A: MA plans include Part A & B automatic-ally—but not all include Part D (if not, buy a Part D plan)
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- 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
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WHEN will the plan take effect?
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- 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.
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- Same as Original Medicare
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- 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
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What are the TYPES of coverage?
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- 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
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- 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
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- Structure: Bronze, Silver, Gold, Platinum “metal plans” & a Catastrophic plan for <30 year olds & those who have a hardship exemption
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What is the PREMIUM in 2015?
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- 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
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- Varies with plan. Plans with lower premiums may have higher out-of pocket costs
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- Varies with plan. Plans with lower premiums may have higher out-of pocket costs
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What are other possible OUT-OF-POCKET COSTS in 2015?
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- 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)
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- Up to $6,700/year for an individual for Part A and B covered benefits
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- 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
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HOW can out-of-pocket costs be paid?
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- 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
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- 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
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- 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.
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What are the options for DRUG coverage?
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- 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
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- 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
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- 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.
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WHEN is drug plan enrollment?
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- 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.
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- 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
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- 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
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How do benefits COORDINATE WITH employer or union plans?
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- 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.
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- 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
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- 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
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How does a patient’s WORK affect plan
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- 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
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- 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
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- 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
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How LONG will the plan last?
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- ≥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
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- 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
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- As long as the premium is paid or the person cancels the plan
- Can switch plans during open enrollment annually
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Comments
chunduru amareswara prasad
Jul 21, 2018 1:43 PM
thank you
laurel Hoffman
Dec 10, 2015 5:12 PM
Beth Witten
Dec 10, 2015 6:49 PM
Swagata Pandit
Jul 06, 2015 1:51 PM
ruth
Jun 15, 2015 4:46 PM
Cindy Paris
Jun 15, 2015 3:48 PM
Beth Witten
Jul 22, 2018 5:28 PM
Beth Witten
Jul 09, 2015 2:29 AM