Sections:

• Eligibility
• How to Enroll in Medicare for ESRD
• When to Apply and Beginning Coverage
• End of ESRD coverage
• Medicare B and Late Enrollment Premium Penalty
• Medicare for ESRD and Employer Coverage
  

Eligibility

You may be eligible for Medicare Part A and Part B no matter how old you are if your kidneys no longer work and you need regular dialysis or have had a kidney transplant, and

• you have worked the required amount of time* under Social Security, the Railroad Retirement Board (RRB), or as a government employee, or
• you are getting or are eligible for benefits from Social Security, the Office of Personnel Management, or the Railroad Retirement Board, or
• you are the spouse or dependent child of a person who has worked the required amount of time* under Social Security, the Railroad Retirement Board, or as a government employee.

* Call the Social Security Administration at 1-800-772-1213 for more information about the required amount of time needed under Social Security to be eligible for Medicare because of End-Stage Renal Disease.

You typically cannot enroll in a Medicare Advantage Plan if you are eligible for ESRD Medicare. However, there are exceptions. See Medicare Reminder: Medicare Advantage and ESRD Medicare- MGH Community News, May 2018.

How to enroll in Medicare for End-Stage Renal Disease

If you are eligible for Medicare because of ESRD, you can enroll in Medicare by calling the Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778. (Railroad workers also should apply through Social Security; only railroad workers who get Medicare based on age or disability enroll through the Railroad Retirement Board.)

Your provider and/or dialysis center should send documentation to Social Security verifying that you have ESRD and stating your treatment needs. If you are unable to enroll yourself due to illness, a family member or other designated party can enroll for you.

You must meet the conditions listed above to be eligible for Medicare. You will need both Medicare Part A and Part B in order for Medicare to cover certain dialysis and kidney transplant services.

When to apply and when does coverage start?

You can apply for Medicare Part A as soon as you are diagnosed with ESRD.

When your Medicare begins depends on your treatment plan:

• If you start a home dialysis training program, sometimes called self-dialysis, you are eligible for Medicare starting the first day of the first month of the home dialysis program. You must start the training program before your third month of dialysis. However, your doctor must also state that he or she expects that you can complete the training program and will continue self-dialysis after the program ends. 
• If you receive dialysis at an inpatient or outpatient dialysis facility, you are eligible for Medicare starting the first day of the fourth month you receive dialysis. For example, if you begin receiving dialysis on May 10, your ESRD Medicare can start on August 1.
• If you are going to receive a kidney transplant, you are eligible for Medicare starting the month you are admitted to a Medicare-approved hospital for the transplant, or for health services you need before getting the transplant.
• You must receive the transplant within two months following the beginning of your coverage. If the transplant is delayed, Medicare coverage begins two months before the month of your transplant.

  -From: Medicare Interactive

When does Medicare coverage for ESRD end?

If you have Medicare only because of kidney failure, your Medicare coverage will end if

• you no longer need dialysis. Your Medicare coverage will end 12 months after the month in which you had your last dialysis treatment.
• you had a successful kidney transplant. A transplant is considered successful if it lasts for 36 months without rejection. If you have a successful transplant, your Medicare coverage will end 36 months after you had the transplant.

Your Medicare coverage will continue if

• you start getting dialysis or have a kidney transplant within 12 months of stopping dialysis.
• you start getting dialysis or have another kidney transplant within 36 months of having a transplant.
• you are age 65 or older.

Medicare B and Late Enrollment Premium Penalty

For Those New to Medicare Who Also Have Employer Coverage- see below Medicare for ESRD and Employer Coverage

For Those Already On Medicare:

I’m over age 65 and only have Medicare Part A. Now that I have End-Stage Renal Disease, can I enroll in Medicare Part B without paying a higher premium? OR I already pay a higher premium because of late enrollment- do I need to continue paying the higher premium?

Yes, you can enroll late in Medicare Part B without paying a higher premium if you enroll in Medicare because you have End-Stage Renal Disease . To enroll in Medicare Part B, you should call the Social Security Administration at 800-772-1213. TTY 1-800-325-0778.

In order to stop paying the higher Medicare Part B premium and begin paying the base premium, call your local Social Security office to make an
appointment to re-enroll in Medicare based on ESRD: 800-772-1213, TTY 1-800-325-0778.

Medicare for ESRD and Employer Coverage

Who pays first?

When you get Medicare because of ESRD, there is a period of time when your employer group health plan will pay first and Medicare will pay second for hospital and medical bills. This is called the 30-month coordination period, and it starts when you first qualify for Medicare coverage, even if you haven’t signed up for it yet. The group health plan pays first during this period no matter how many employees work for your employer, or whether you or a family member are currently employed.

At the end of the 30-month coordination period, Medicare will pay first for all Medicare-covered services and your employer group health plan will pay second. (Your employer group health plan may also pay for services not covered by Medicare. Call your benefits administrator to find out.) This rule applies to most people with ESRD, whether you have your own group health plan coverage or you are covered as a family member.

-From Medicare and Other Health Benefits: Your Guide to Who Pays First (CMS Pub. No. 02179).

Can I delay Medicare B coverage?

Because most people have to pay a monthly premium for Medicare B ($104.90/month in 2016) some who have employer coverage may want to delay taking part B. There are risks and benefits to this approach- we advise discussing the pros and cons with your dialysis social worker. Some things to consider: you should usually enroll in Medicare when you first qualify, even if Medicare will not be primary. This is because people with ESRD need a lot of medical care and Medicare will pay second on all claims. This means Medicare will pay for deductibles, copays and coinsurances that your employer insurance does not cover. Medicare can also place limits on the amount a provider can charge you. Furthermore, if you need an organ transplant and have Medicare when you get the transplant, Part B will cover your immunosuppressant (anti-rejection) drugs after the 30-month coordination period ends. If you did not have Medicare at the time of your transplant, you will have to pick up a Part D plan to pay for your immunosuppressant drugs at the end of your 30-month coordination period.

Delaying ESRD Medicare - If you have good employer insurance and you do not need Medicare to supplement your coverage, you can delay enrollment in Medicare and avoid paying the monthly Medicare Part B premium. To do so without incurring a premium penalty charge when you enroll later, you have to turn down both Part A and Part B when you first become eligible for Medicare. You should then enroll in both Part A and B just BEFORE your 30-month coordination period ends in order to avoid having any gap in coverage and paying a premium penalty.

If you wait to enroll in Medicare until AFTER your 30-month coordination period, you will NOT be entitled to a Special Enrollment Period (SEP)*. You will only be allowed to enroll in Part B during certain times of year and may be subject to a premium penalty.

Be sure to talk to your employer before deciding to delay Medicare coverage. Ask how your costs will compare if you have employer coverage alone versus employer coverage and Medicare.

*The Special Enrollment Period (SEP) is a period of time outside of the general enrollment period, Fall Open Enrollment Period or Medicare Advantage Disenrollment Period triggered by specific circumstances, during which you can enroll in Medicare Part B, Part D, or a private health plan (Part C). SEPs may also allow you to switch or disenroll from Part D and private health plans. In Part B, an SEP absolves you from having to pay a premium penalty for late enrollment.

(This section from Medicare Interactive)

 

For more information call 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048.

 

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