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    « Singapore 2004 | Main | CMS to release new dialysis CfCs? »

    March 27, 2008

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    Sean Davis

    What occurs at age 65 if an individual had qualified for Medicare at age 63.5 (having begun dialysis treatment at that same time) while also being insured by her husband's plan? Since she has reached the attained age should she drop the coverage provided by her husband and will Medicare kick-in fully, or will she need to stay with that same private plan for the 33 months you detail? One question is she better served assuming a Medicare Supplement upon her birthday to cover the potential gap in insurance? I guess we're confused by the 30 month waiting period in light of having passed the age threshold you describe, and how she might be best served now that she falls in the open enrollment period for a Supplement. It appears to be preferable to drop the private insurance if possible, especially if Medicare plus the Supplement could cover everything.

    RenalSW

    When a patient who has paid enough Social Security taxes develops kidney failure, he/she will become eligible for Medicare. Kidney failure is the only disease where a worker's spouse or child who has kidney failure can get Medicare based on the worker's record.

    When Medicare starts and whether it pays first or second depends on 1) the type of treatment the patient chooses and 2) whether the patient has an employer group health plan (EGHP).

    When a patient chooses to do in-center dialysis, Medicare starts the first day of the third full month of dialysis. If that patient chooses to start a training program for home dialysis (peritoneal dialysis or home hemodialysis) before the first day of the third full month, Medicare can be backdated to the first day of the month dialysis started. If someone gets a transplant as his/her first treatment, Medicare can start the month of the transplant. In some cases Medicare can be backdated up to 2 months if the patient was admitted for transplant evaluation during that time.

    If someone is covered by an EGHP through own or another's current or former employment and that plan is paying primary when he/she develops kidney failure, it doesn't matter what his/her age is. The Medicare secondary payer (MSP) rules require the EGHP to pay first for the first 30 months that the patient is eligible for Medicare. The clock starts whether or not the patient signs up for Medicare. Because of the waiting period, in-center patients' Medicare won't be primary for 33 months.

    If your wife has kidney failure and retires, the EGHP is still liable to pay first until the end of the 30 month coordination period and Medicare can be billed for deductibles and copays or coinsurance. Even if Medicare pays nothing, the benefit of having Medicare is that it limits what providers that "accept assignment" can charge. If the EGHP pays at least as much as 100% of the Medicare allowable for the services, the provider must write off any balance owed for those services. If services are provided that Medicare doesn't cover, and the EGHP leaves balances for them, the provider can charge the patient for them, but should inform the patient first.

    So far as whether to drop the EGHP...It is usually best to keep EGHP coverage if you can afford it because it may offer coverage for things that Medicare doesn't cover, like dental, vision, routine check-ups, drugs, etc. A Medicare supplement plan only covers those things that Medicare covers and in some states, people can't get a Medicare supplement plan until they turn 65 even if they have Medicare before that. If you like to travel, Medicare won't pay for care outside the U.S. or its territories where some private insurances will. Also, Medicare doesn't cover most take-home drugs so most dialysis patients that don't have an EGHP or drug coverage through another source pay a premium to have Medicare Part D (drug coverage).

    My advice is to contact the benefits administrator at the employer or call the health plan to and ask about coordination of benefits with Medicare and whether any drug coverage is as good as Part D. If not, I'd suggest your wife sign up for Part D as soon as possible.

    You can call 1-800-MEDICARE to ask about Part D and to request the booklet that Medicare publishes on coverage of dialysis and kidney transplant and the booklet on Medigap (Medicare supplement) insurance. You can also read the booklet Employment: A Kidney Patient's Guide to Working and Paying for Treatment on www.lifeoptions.org (see booklets under "free materials").

    Paul Si

    A good source of good info on dialysis-related financial miseries for a new patient.

    Jonathan Finger

    Bill, Jonathan here - long time no see. :)

    Quick question:
    I've always understood it to be that dialyzors have no choice after the 33 month coordination period, and must (by law) become Medicare primary.
    In reading Medicare documentation last night it was clear that a dialyzor can choose not to enroll in Medicare right away, but what happens then at the end of the coordination period if a younger person doesn't enroll in Medicare? Must they enroll in Medicare before the end of this period, or will their private insurance (let's assume group plan through employer) keep covering costs indefinitely?

    Bill Peckham

    Hi Jonathan - it's good to see you!

    I think the person to ask about insurance/Medicare is Beth Witten who helpfully answers questions on her own forum over at Home Dialysis Central
    http://forums.homedialysis.org/forumdisplay.php/17-Beth-Witten-Social-Worker

    Beth will be able to give you an authoritative answer.

    Jonathan

    Thanks a lot Bill - I will follow up with her.

    Ed

    Hello all. I am so confused about this. My wife has just started dialysis. My wife is under age 65. I currently have private insurance. I called the dialysis social worker and asked if I should put her on Medicare. They said no, that I should not apply for Medicare and that there were ways to even have my wifes private insurance paid for (which they would help arrange). The social worker even suggested there is better care for those with private insurance. This all sounds a bit fishy to me. My wife is under age 65. Any suggestions?

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