2019 - Health Insurance 101: Options for People with ESRD

• Citizen or legally present for >5 years

• Age 65 or older

• Receiving SSDI for >2 years

• Have ESRD requiring dialysis or transplant

• Citizen or legally present in US >5 years

• Live in plan’s area

• If on dialysis, can enroll only in a Special Needs Plan (SNP) accepting ESRD (limited plans); 1/2021 will be able to enroll in any MA plan

• If transplanted: not on dialysis can enroll in any MA plan

• Citizen or legally present and not incarcerated

• Can’t join if have Medicare Part A and/or Part B, full Medicaid or CHIP

• Can keep after enrolling in Medicare, but lose tax credits and subsidies; individual plans don’t pay Medicare out-of-pocket costs

• Initial Enrollment Period (IEP): 7 mo period starting 3 mo. before eligible mo. through 3 mo. after eligible mo.

• General Enrollment Period (GEP): If Part A was taken alone at first, can only apply for Part B 1/1-3/31 each year & Part B takes effect July 1^st

• 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 10/15-12/7 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 1/1-2/14; before switching, have a plan for how to pay Original Medicare out-of-pocket costs.

• Yearly 11/1-12/15

• Special Enrollment: Limited time to enroll if household or residence changes, other health coverage is lost, and some less common events

• 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

• Can only enroll in Part B during the general enrollment period (1/1-3/31) with Part B starting in July; could have gap in coverage

• MA plans include Part A & B automatically—but not all include Part D (if not, buy a Part D plan)

• May keep ACA QHP plan but…

• There is a premium penalty if delay enrolling in Medicare beyond IEP

• 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 1^st month of dialysis or pre-emptive transplant.

• Medicare may backdate up to 2 months before a transplant to cover a patient’s admission for evaluation

• Same as Original Medicare

• Apply 11/1-12/15, & plan starts Jan. 1

• With a special enrollment period, coverage starts the month after enrollment

• 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, and other services not covered by Original Medicare like vision, dental, hearing, exercise

• Care Network may be more limited than Original Medicare

• Bronze

• Silver (option for those needing subsidies to pay out-of-pocket costs)

• Gold

• Platinum

• Catastrophic plan, for <30-years old & those who have a plan cancel, hardship or affordability exemption; lowest premium, highest deductible, may limit number of visits and providers

• Part A: Free with enough work credits based on age (ask Social Security)

• Part A: Free If 65 or older with too few work credits, can buy Part A for $437/mo with <30 credits or $240/mo with 30-39 credits

• Part B: $135.50/mo, or more if income is >$80K single/$160K couple

• State may pay A&B premiums if someone qualifies for certain Medicare savings programs

• 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

Part A (hospital):

• Days 1-60: $1,346 deductible, no copay

• Days 61-90: copay $341 per day

• NOTE: Get back days 1-90 if out of hospital 60 days

• Days 91-150 (lifetime reserve days once used they’re gone): copay $682/day

• Day 151 on: all costs

Part B (medical):

• Deductible: $185/year

• Coinsurance: 20% of allowed charge (with no maximum)

• Out-of-pocked maximum up to $6,700/year for an individual for Part A and B covered benefits; a few plans have lower caps

• Out-of-pocket maximum $7,900/year/ for an individual plan or $15,800/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

• 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

• Full Medicaid, if qualify: pays Medicare out-of-pocket costs

• Medically Needy Medicaid (not in all states): pays costs over “spenddown” (like a deductible)

• Medicare Savings Programs, if qualify: QMB, SLMB, QWDI pay Part A and/or B premiums, QMB pays Medicare out-of-pocket costs too

• Other health insurance plan: employer or union health plan, private plan off the marketplace pays as per policy

• Medicaid if eligible

• Cannot use Medigap

• There are Special Needs Plans (SNPs) for those with both Medicare & Medicaid

• Income of 100-400% of the federal poverty level may qualify for a premium tax credit

• Income of 100-138% of the federal poverty level (some states allow higher income) may qualify for lower out-of-pocket costs (Silver plan)

• No premium tax credits or cost saving subsidies if income is <100% of federal poverty

• Medicare Bundle: Some ESRD-related drugs are covered under the rate paid for dialysis

• Part B covers some drugs, including anti-rejection IF Part A was in effect the transplant month; Part B will never cover anti-rejection drugs if Part A was not in effect the transplant month; if not, Part D covers

• Part D: Private companies sell these plans; have lists of covered drugs & costs vary from plan-to-plan and drug-to-drug

• State Pharmacy Assistance Programs (where offered) can help

• State kidney programs (if available) may help

• Drugs are often covered in MA plans; anti-rejection covered under Part B or D depending on whether patient had Part A the transplant month; other drug copays vary

• If MA plan has no drug coverage, may buy a Part D plan; covered drugs & costs vary

• State Pharmacy Assistance Programs (where offered) may coordinate with MA drug plan differently from Original Medicare

• Drugs are included in the basic benefit

• Formulary & costs vary

• A transplant recipient may want to review these plans if after 36 months post-transplant & Medicare ends & not eligible for another plan, not age 65 or older and not disabled for another reason.

• Initial Enrollment Period (IEP) is the same as the 7 mo. Part A and/or B IEP. IEP. If Medicare is backdated, IEP start is based on the Medicare award letter date.

• If you have an employer group health plan, ask if enrolling in Part D will affect your employer plan’s health or drug coverage

• Yearly: 10/15-12/7

• Medicaid, those receiving “extra help” due to limited income or in nursing homes can switch once/quarter. The new plan starts the next month.

• Initial Enrollment Period Same as Original Medicare

• Ask if enrolling in separate Part D plan will affect your employer plan’s health or drug coverage.

• 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 QHPs and Small Business Health Options Program (SHOP) plans sold on the Marketplace)

• 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

• Can have Original Medicare with a union/employer plan

• Employer plan pays 1^st for 30 months from 1^st mo. eligible for Medicare. Providers who agree to accept Medicare allowed payment cannot bill you for unpaid balances over that amount.

• After 30 months, Medicare pays 1^st and union or employer plans pay 2^nd. As a secondary payer, union or employer plans may have out-of-pocket costs.

• Some employers/unions may enroll their Medicare employees in a group MA plan or an individual MA plan.

• 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 SHOP

• If someone has Medicare & a SHOP plan, payment follows Medicare secondary payer rules like Original Medicare

• People on dialysis can work & keep Medicare (see section on coordination of benefits)

• Employer plans pay first for transplant recipients 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

• Same as Original Medicare

• If eligible for a SHOP plan the premium can’t be more than 9.86% of the employee’s income to be considered “affordable.” If not affordable, person can choose to enroll in a QHP instead to get premium tax credits and subsidies, if eligible.

• ≥65: as long as premiums are paid

• On dialysis: as long as dialysis continues

• As long as SSDI checks continue

• Kidney function improves (dialysis not needed): 12 mo

• Transplant: 36 mo.

• “Continuation of Medicare”: 93 mo after trial work period ends if disabled

• “Medicare for People with Disabilities Who Work”: after 93 mo pay Part A, B, & D premiums to keep Medicare

• “Section 301” can help transplant patient who is in a VR or other program whose goal is to end benefits when SSA says s/he has medically improved; s/he keeps SSI & Medicaid or SSDI & Medicare until program ends, s/he leaves the program, or SSA decides the program is unlikely to prevent return to disability rolls.

NOTE: If SSDI ends before 36 months after transplant, Part B premium won’t be paid with SSDI, so prepare to pay premium another way to keep Medicare

• Same as Original Medicare

• As long as the premium is paid or until the plan is cancelled

• Can switch plans during open enrollment annually