January 2015 Medicare Benefits, Options, and Transitions Rules for People with ESRD - PowerPoint Presentation

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January 2015

Medicare Benefits, Options, and Transitions Rules for People with ESRD

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hese SlidesYou can download and print off these slides at www.ncoa.org/ncboewebinars Or check the Events tab on ncoa.orgSlide6

Let’s Learn MedicareMedicare Benefits, Options, and Transitions Rules for People with ESRDSlide7

Medicare Rights CenterThe 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 advocacyEducational programs

Public policy initiativesSlide8

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

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This training will coverParts of MedicareMedicare eligibility and enrollment for people with End-Stage Renal Disease (ESRD) also known as kidney failureMedicare coverage and costs for ESRD treatment

Other types of insurance and ESRD MedicareThe 30-month coordination periodCoverage of immunosuppressant drugs after a kidney transplantMedigap, Medicare Advantage plans, and Part D enrollment for people with ESRDESRD and the Health Insurance Marketplaces Note: Eligibility, enrollment and coordination of benefits work differently for ESRD Medicare than for Medicare based on age or disability. However, Medicare covers medical care for ESRD the same way as it covers care for people with Medicare due to age or disability. Slide10

Parts of MedicareMedicare benefits administered in three parts:Part A – Hospital/Inpatient BenefitsPart 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 planAdministered by a private insurance companyNot a separate benefit: everyone with Medicare Advantage still has MedicareSlide11

Medicare Eligibility and Enrollment for ESRD PatientsSlide12

Medicare eligibility based on ESRDSomeone is eligible for Medicare if: The person has End-Stage Renal Disease (ESRD), meaning that they have permanent kidney failure that requires dialysis or a kidney transplant; and

The person, their spouse, or their parent has enough Medicare work history to qualify for Social Security or Railroad Retirement benefits (RRB)Slide13

When Medicare begins with ESRDThe date when someone’s Medicare benefits begin depends on the type of treatment they receive

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 someone does not choose to sign up for Medicare No waiting period

Medicare begins the same month as the home dialysis training program A doctor must expect that the beneficiary can finish the training program and continue home dialysis after it ends No waiting period Medicare begins the month someone goes into a Medicare-approved hospital for the transplant or the health care services needed before the transplant—as long as they get the transplant over the following two monthsSlide14

Enrollment case examplesDialysis at a facilityMsSelf dialysisM

Kidney transplantMSlide15

End of Medicare coverage for ESRDIf an individual has Medicare only because of ESRD, Medicare coverage will end:12 months after the month the individual stops dialysis treatments

or36 months after the month of a successful kidney transplantIf they have Medicare based on ESRD and then enroll in Medicare based on disability or age, Medicare enrollment continuesNote: If they had Medicare ESRD and it terminated, Medicare coverage will start again without a waiting period if they begin dialysis again or get another kidney transplantSlide16

Medicare eligibility for children with ESRD Children can qualify for Medicare: must have ESRD and have at least one parent who has sufficient Medicare work historyChildren are:People who are unmarried and age 21 and youngerPeople ages 22 to 25 in certain circumstances

Adult dependent childrenSlide17

Medicare, ESRD, and ageIf an individual has Medicare based on age first, they do not need ESRD Medicare unless:They need an earlier Medicare start date

ESRD Medicare can be retroactive up to one yearThey did not enroll in Part B during their Initial Enrollment Period and want to enrollThey get another IEP to enroll in ESRD Medicare Part B without premium penaltiesThey already have Part B but pay a premium penalty because they enrolled late Enrolling in ESRD Medicare Part B will remove the premium penalty due to delayed Part B enrollmentSlide18

Medicare, ESRD, and disabilityIf an individual qualifies for Medicare based on disability first, they may want to enroll in ESRD Medicare if:They are still within their 24-month waiting period for Medicare based on disability

ESRD Medicare will start earlier than their Medicare for disability will They declined Part B during their Initial Enrollment Period and want to enrollThey get another IEP to enroll in ESRD Medicare Part B without premium penaltiesSlide19

How to enroll in ESRD MedicareIndividual eligible for ESRD Medicare should enroll by calling Social Security (800-772-1213) or visiting local Social Security office For incapacitated individual, a family member or other responsible party can also enroll for them

Eligible individual’s dialysis facility must complete and send a form to the Social Security Administration to confirm ESRD status and the type of treatment neededSlide20

Medicare coverage of ESRD treatmentMedicare covers: Kidney transplants

Immunosuppressive drugs after a Medicare-covered kidney transplantAs long as the person still qualifies for Medicare and has Part BHospital inpatient dialysisOutpatient dialysis from a Medicare-certified hospital or free-standing dialysis facilityHome dialysis training, equipment, supplies, and medications from a dialysis facilityMedication is only covered when overseen by a physicianNote: Medicare covers all ESRD treatments the same way, regardless of whether someone has ESRD Medicare or Medicare due to age or disability.Slide21

ESRD Medicare costsMedicare Part A Costs for 2015

Premium Free for those with 10 years of Social Security work history $224 if you or your spouse worked and paid Medicare taxes for 7.5 to 10 years $407 if you or your spouse worked and paid Medicare taxes for fewer than 7.5 years

Hospital deductible$1,260 for each benefit periodHospital copay $315 per day for days 61-90 each benefit period $630 per day for days 91-150 (these are 60 non-renewable lifetime reserve days)

Skilled nursing facility

copay

$157 per day for

days 21-100 each benefit period

Original Medicare costs apply for people with ESRD Medicare:Slide22

ESRD Medicare costsNote: coinsurance is sometimes called cost sharing

Medicare Part B Costs for 2015Annual deductible$147

Monthly premium$104.90 per monthPeople with high incomes pay more for the monthly premiumCoinsuranceMedicare pays 80% of Medicare-approved amount for a doctor’s service; you pay 20% coinsurance

Original Medicare costs apply for people with ESRD Medicare:Slide23

Medicare and other types of insurance for people with ESRDSlide24

What to consider before enrolling in MedicareHow employer coverage coordinates with ESRD MedicareHow Medicare covers immunosuppressive drugs after someone has a kidney transplantSlide25

Employer insurance and MedicareFor people with ESRD Medicare, employer insurance can be any combination of: Active employer coverage from beneficiary or their spouse

Retiree insuranceUnion coverageCOBRAEmployer coverage is primary to Medicare for the first 30 months a person qualifies for Medicare based on ESRDThe 30-month coordination periodNote: 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. Slide26

The 30-month coordination periodDuring 30-month coordination period

Coordination period begins the month someone becomes eligible for Medicare Employer insurance pays primary to Medicare during this time Individual does not have to enroll in Medicare if they have other coverageYou have until the end of the 30- month coordination period to enroll in MedicareAfter 30-month coordination period

Medicare becomes primary payer Must be actively enrolled in Medicare This change will occur automatically, even if the individual never actively enrolled into Medicare Slide27

Employer insurance and ESRD MedicareIf individual is enrolled in ESRD Medicare, it is the secondary payer during the 30-month coordination period

This means that employer insurance pays first and Medicare pays second This is true for both insurance based on current employment and retiree insurance The 30-month coordination period starts when they first qualify to receive ESRD Medicare, even if they have not signed up for it yetAfter the 30-month coordination period, ESRD Medicare pays primary to employer coverageThis switch is automatic and happens even if someone never actively enrolls in ESRD MedicareSlide28

Taking Medicare for those with employer coverageIf an individual has employer coverage, it may still be best to enroll in ESRD Medicare when they first qualifyMost cost effective way to get care

ESRD patients need a lot of medical careEven if employer coverage is primary to ESRD Medicare, the individual may still have deductibles, copays, and coinsurancesMedicare will pay second and could help pay these costsMedicare will also place limits on the amount providers can chargeIf they need an organ transplant and have Medicare when they get the transplant, Part B will cover their immunosuppressant drugsPeople should talk to their employer before deciding to delay ESRD Medicare coverageAsk how costs will compare if they have employer coverage alone versus employer coverage and MedicareSlide29

Delaying Medicare for people with employer coverageIf a person decides to delay ESRD Medicare enrollment:Delay enrollment in both Part A and Part BThis means they

should not enroll in Part A and should decline Part BIf they defer enrollment in both Parts A and B, they can enroll in both parts at any time while they still have ESRD If they enroll in Part A and decline Part B, they may have gaps in coverage and higher costsThey will only be allowed to enroll in Part B during the General Enrollment Period (GEP) (January 1 – March 31 of each year)Premium penalty will apply for each 12-month period they delayed enrollmentSlide30

Delaying Medicare for people with employer coverageTo prevent a gap in coverage, individual should apply for ESRD Medicare Parts A and B a few months before 30-month coordination period ends Ask for Medicare to begin the month after their coordination period ends. Remember:

30-month coordination period begins the month a person becomes eligible for MedicareAfter 30-month coordination period, Medicare pays first and employer insurance pays second Once Medicare becomes primary, employer coverage can refuse to cover someone if they failed to enroll in Medicare If individual had kidney transplant, they should enroll in Medicare within one year of their transplant to make sure Medicare will cover immunosuppressive drugsSlide31

Medigaps, Medicare Advantage, and Part D for people with ESRDSlide32

Medigap policies for people with ESRDMedigap policies (Medigaps, also known as Medicare supplemental insurance): sold by private insurance companies, used to pay the costs associated with Original Medicare Many people with Original Medicare purchase a Medigap

to help pay Parts A and B cost-sharingFederal law does not require Medigap insurers to sell Medigaps to people with ESRD who are under age 65States may have additional protections that allow someone with ESRD to purchase a Medigap policySlide33

ESRD and Medicare Advantage plansMost people with ESRD cannot join a Medicare Advantage plan. Two exceptions:If individual has ESRD, can join a Special Needs Plan (SNP) that specifically accepts people with ESRD, if there is one in their area

SNP: type of MA plan that specifically serves members who have a particular need, such as a chronic illnessIf individual has employer health plan coverage through the same insurance company that offers a MA plan, can enroll in that company’s MA plan If ESRD develops after individual joins a MA plan, plan cannot disenroll themIf the plan leaves Medicare, individual has one-time Special Enrollment Period (SEP) to join another plan in their area Slide34

Enrolling in a Part D plan with ESRDIndividuals with ESRD Medicare can enroll in a Part D plan as they would with any other type of Medicare eligibility People with employer coverage should talk to their employers to see how Medicare Part D would coordinateMany people with employer coverage may not need Part D

They can delay Part D without penalty if they have creditable coverage and join a Part D plan within 63 days of losing that coverageBefore joining a Part D plan, beneficiaries should make sure it will not cause their employer coverage to end for them or their familyIf they do not have employer coverage, they should take Medicare Part D to help cover all their drug costs Slide35

Part D coverage of ESRD-related drugsA Part D plan must cover individual’s immunosuppressant drugs if they do not qualify for Part B coverage for them All Part D formularies must include most all immunosuppressive drugs

Step therapy not allowed once individual is stabilized on immunosuppressant drugHowever, prior authorization can apply to verify that Part B won’t cover needed drugs even after individual is stabilized on themIndividuals should double check to make sure the drugs they need are covered with the fewest restrictions and that their plan includes their pharmacy as a preferred network pharmacySlide36

ESRD and low-income programsIndividuals with ESRD Medicare can qualify for low-income programs to help with Medicare costs, such as:Medicare Savings Programs (MSP)

Extra HelpMedicaid If an individual qualifies, Medicaid can provide secondary coverage to MedicareIf individual has Medicaid and then develops ESRD, they will likely have to enroll in MedicareContact local Department of Social Services or State Health Insurance Assistance Program (SHIP) for more information regarding these programsSlide37

Medicare Coverage of Immunosuppressant DrugsSlide38

Medicare coverage of immunosuppressantsAfter an individual has a kidney transplant, they will need to take immunosuppressant drugs for the rest of their lives to prevent body from rejecting organNormally,

immunosuppressants are covered under Part A at the time of a Medicare-covered transplantFor post-discharge patient, Part B covers immunosuppressive drugs if:Individual had Part A at the time of their transplant, and Individual continues to have Part B If they qualify for Medicare on the basis of ESRD alone, Medicare will end 36 months after a successful transplantMedicare will not cover drugs after coverage ends If they qualify for Medicare on another basis (age or disability), Medicare will not end and will continue to cover their immunosuppressive drugsSlide39

Medicare coverage of immunosuppressantsIf individual did not have Medicare when they had a transplant, there are two ways to get coverage: Enroll retroactively in Part A if it is within a year of their transplant

Get coverage under their Part D plan since they do not qualify for Part B coverage of their drugsSlide40

ESRD and the Health Insurance Marketplaces Slide41

Health Insurance MarketplacesA 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 plansQHPs purchased by individuals through the Marketplace = QHPsMarketplace operations vary by stateSlide42

ESRD and the MarketplacesSHOP plans work with ESRD Medicare the same way that other employer coverage doesAnyone who has any part of Medicare already cannot purchase a QHP

Most people with Medicare are not eligible for tax credits to purchase QHPsPeople with ESRD are eligible for tax credits if they have not yet enrolled in any part of Medicare People with ESRD who have QHPs first can keep those plans after they’ve taken MedicareCan still qualify for premium tax credits if they are under age 65People with ESRD can choose to not enroll into Medicare and take a QHP insteadSlide43

ESRD and the MarketplacesWhat form(s) of insurance to choose depends on many factors:Medical costs

Existing insurance (i.e. employer insurance)Coverage needs If someone decides to forego ESRD Medicare and enroll in QHP, it is best practice to get written confirmation from the QHP that it will provide primary coveragePeople with ESRD who are considering a QHP instead of or in addition to Medicare should do an analysis of QHP costs and coverage against their own needsWhen someone with ESRD turns 65 or becomes eligible for Medicare due to a disability, they should enroll in MedicareSlide44

For more information and helpLocal State Health Insurance Assistance Program (SHIP)www.shiptacenter.org

www.eldercare.gov Social Security Administration800-772-1213 www.ssa.gov Medicare800-MEDICARE (633-4227)www.medicare.govMedicare Rights Center800-333-4114www.medicareinteractive.org

National Council on Agingwww.ncoa.org www.centerforbenefits.orgwww.mymedicarematters.org www.benefitscheckup.org Slide45

Medicare InteractiveMedicare Interactivewww.medicareinteractive.orgWeb-based compendium developed by Medicare Rights to be used as a counseling tool to help people with Medicare

Easy to navigateClear, simple languageAnswers 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

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