what medicare, medigap, medicaid, and medicare savings ... · pdf filemedicare calls end-stage...

This chapter is about programs that can help pay a large part ofthe cost of medical treatment for

your kidney disease. Medicare Parts A and B, Medicaid, and MedicareSavings Programs are available throughagencies of the federal and stategovernments. Medigap and MedicarePart D (Prescription Drug Coverage)can be purchased from some insurancecompanies. The details of these programschange often, so be sure to check thephone numbers and Web sites listed.Also check with your social worker tobe sure you have the most up-to-dateinformation.

MMeeddiiccaarree——ffoorr ppeeooppllee wwiitthh aa wwoorrkk hhiissttoorryyMedicare is not just for people who are65 and older. The program also helpsAmericans and legal residents of allages who need dialysis or a kidney

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transplant. More than 90 percent ofAmericans with kidney failure, whatMedicare calls End-Stage Renal Diseaseor ESRD, have Medicare. If you (or yourspouse or parent) have worked longenough to qualify for Medicare, it willpay most of your treatment costs, plussome or all of the costs for hospital stays,doctors’ visits, and other services. Inaddition, once you are on Medicare, it will cover other health problems notrelated to kidney disease. You can get a free booklet that tells you howMedicare helps to pay for dialysis andkidney transplants. Call 1-800-MEDICARE (1-800-633-4227) and ask for a copyof Medicare Coverage of Kidney Dialysis and Kidney Transplant Services,Publication No. CMS-10128. You also can print or order it online atwwwwww..mmeeddiiccaarree..ggoovv. Click Find aMedicare Publication under SearchTools and type in the publication name.

Medicare has three parts:

• Part A is hospital insurance that helpspay for hospital room and board,drugs and supplies while you are inthe hospital, inpatient rehabilitationservices, and lab tests, as well as fortransplant testing and surgery, somenursing home care, hospice care,and some home health care. There isno monthly premium for this part ofMedicare if you need dialysis and ifyou have enough work credits. (See“Number of Work Credits Needed toQualify for Medicare” on page 21.)

If you are 65 or older, and you don’thave enough credits, you may beable to get coverage by paying apremium. How much you pay dependson how many work credits you have.

Everyone in Part A must pay aspecific amount of money, called adeductible, each benefit period beforeMedicare will pay (the deductible in2006 is $942). A new benefit periodstarts after you’ve been out of thehospital, nursing home, or rehabilita-tion center for 60 days. If you havea long hospital stay, you may haveto pay some for each day, too. CallSocial Security at 1-800-772-1213or your local Social Security officeand ask if you qualify for free Part Abenefits or if you can buy coverage.You also can visit wwwwww..mmeeddiiccaarree..ggoovvand click Find Out If You Are Eligiblefor Medicare and When You CanEnroll under Search Tools.

• Part B helps pay for most of the otherservices and supplies that peoplewith kidney failure need, includingdoctors’ services, dialysis, outpatienthospital care, and other medicallynecessary services Part A does notcover. There is a monthly premiumfor Part B services ($88.50 in 2006)and an annual deductible ($124 in2006). You do not have to enroll inPart B at the same time you enroll inPart A, but your monthly premiumwill be 10 percent higher for every12 months you delayed enrolling in

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Part B. You also will only be able toenroll in Part B from January throughMarch each year, and coveragewon’t start until July 1.

• Part D is a new drug plan that beginsJan. 1, 2006, to help people onMedicare save money on prescriptiondrugs. (Drug discount cards wereissued in 2004–2005 to temporarilyhelp people on Medicare pay fordrugs. If you have one of these cards,you can continue to use it throughMay 31, 2006, or the date youenroll in Part D, whichever comesfirst.) You may have to pay a monthlypremium to be in Part D (average$32 in 2006), as well as a deductible($250 in 2006), 25 percent co-insurance, and 100 percent of costsduring a coverage gap for eachprescription. The amount you paydepends on your income and assetsand whether the drugs you need arecovered by your plan. If you havelittle income and few assets, youmay not have to pay premiums ordeductibles, but you could have asmall co-payment per drug.

For most, Part D is voluntary, so youcan choose to be in it or stay with a drug insurance plan you havethrough your employer or Medigap.If you are already on Medicare, youmust enroll in Part D by May 31,2006 to avoid higher premiums. Ifyou start Medicare in 2006 or futureyears, you have six months to enroll

in Part D. If you don’t sign up inthose time frames, your premiumsmay be higher and you will only beable to enroll between Nov. 15 andDec. 31 each year.

If you have Medicare and Medicaid,you must take Part D because itreplaces Medicaid coverage fordrugs as of Jan. 1, 2006. If youdon’t have Medicaid, but haveMedicare, Supplemental SecurityIncome, and receive help from yourstate to pay Medicare premiums, youmust take Part D by May 15, 2006.

Part D plans are offered by privateinsurance companies and eachcompany’s plan may cover differentdrugs. Before you sign up for anyplan, be sure to find out if it coversthe drugs you take now and thoseyour doctor thinks you may need inthe future. Part D plans could savepeople with kidney disease andkidney failure money on the cost of drugs for high blood pressuremanagement and blood sugar control,lipid lowering drugs, prescriptionOral Vitamin D, phosphate binders,and other drugs the plan covers.Transplant recipients also couldreceive help paying for intravenousimmune globulin, oral infectiontreatments, and antiviral agents thatare not covered by Medicare Part B.Coverage for immunosuppressantswill continue to be provided by

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Medicare Part B unless Congresschanges the Medicare law. However,transplant patients whose immuno-suppressant drugs are not coveredby Medicare can get help from PartD for those drugs if they are coveredby the plan. To learn about Part Dplans and if you qualify for a planwith little or no premiums anddeductibles, call Medicare at 1-800-MEDICARE (1-800-633-4227)or visit wwwwww..mmeeddiiccaarree..ggoovv. Click Learn About Your MedicarePrescription Coverage Options under

Search Tools. You might also visitwwwwww..kkiiddnneeyyddrruuggccoovveerraaggee..oorrgg forkidney-specific information aboutPart D.

You need Part A and Part B if you wantMedicare to help pay for dialysis andtransplant services. You must be enrolledin at least Part A in the month you havea kidney transplant to have MedicarePart B ever pay for your immuno-suppressant drugs. Part D also mayhelp pay for these drugs.

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Your Age Now Number of Work Credits Needed to Qualify for Medicare

You earn one work credit for earning a specific amount of money ($920 in 2005)from work in a three-month quarter; call Social Security at 1-800-772-1213 andask how many work credits you have

Under 24 6 credits in the last 3 years before kidney failure

24–30 Worked at least half the time from age 21 until kidney failure

For example, if you are 30, you must have at least 18 credits (9 years of work x 2quarters each year = 18)

31–43 20 credits in the 10 years before kidney failure

44–61 20 credits in the last 10 years, plus 2 credits for every 2 years age 44 and older

For example, if you are 58, you must have at least 36 credits (10 years of work x 2 quarters each year = 20, plus 8 two-year periods since age 44 x 2 credits each year = 16)

62 & older 40 credits

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Following are some of the costsMedicare will pay. The amount willdepend on the type of Medicare HealthPlan in which you are enrolled. There is the Original Medicare Plan andseveral Medicare Advantage Plans(previously called Medicare + Choiceand sometimes called Part C). If youhave kidney failure and are on dialysis,you may not be able to join a MedicareAdvantage Plan now, but, if you are in an Advantage Plan when you arediagnosed, you can stay in it. The

costs and percentages quoted in thetable starting on page 23 are thoseMedicare will pay if you are in theOriginal Medicare Plan and it is your primary (first) payer. If you havehealth insurance through an employer,Medicare may be your secondary(second) payer. See “How Medicareworks with your health insurance” onpage 32. You may have to pay theannual deductible before these per-centages apply. For an overview ofMedicare benefits, request a copy ofMedicare & You, Publication No. CMS-10050 in 2006, at wwwwww..mmeeddiiccaarree..ggoovv.Click Find a Medicare Publication andthen Medicare & You. You also mightwant to get a copy of Your MedicareBenefits, Publication No. CMS-10116,from the same Web site.

Paid by Paid by Medicare Part B Paid by Medical Cost Medicare Part A as Primary Payer Medicare Part D

Hospital stays Pays all costs but:

• $952 deductible (2006) for days 1–60*

• $238 per day (2006) for days 61–90*

• $476 per day (2006) for days 91–150 (lifetime reserve days you can use only once)

* Available again after you’re out of the hospital or skilled facility for 60 days or longer

Will pay for surgery needed to prepare for dialysis only if it is done after Medicare coverage begins

Skilled nursing home All costs for up to 20 days if requirements are met; pays set amount ($114/day in 2005) for days 21–100

Home health care 100% for services; 80% for durable medical equipment

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23(continued on page 24)


Hospice care 100% of outpatient care; All but $5 per prescription for 95% of short-term inpatient outpatient pain medications care if requirements are met and symptoms control

Medicare will pay separately from the hospice benefit for symptom relief dialysis if kidney failure is not the terminal illness requiring hospice care

Dialysis-related Medicare pays 80% of the services in a Medicare-allowed treatment Medicare-approved cost, called the composite rate. dialysis facility The composite rate depends

on the type of clinic (free-standing or hospital-based)and location. The average composite rate in 2005 was about $141 and is adjusted to each person’s characteristics.Medicare also pays 80% of the Medicare-approved amount for covered services not included in the composite rate.

Transportation to Covers round-trip ambulance dialysis facility services from home to the

nearest dialysis center or hospital emergency room only if your doctor says that other forms of transportation would be harmful to your health or if there is a medical emergency

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(continued from page 23)


Dialysis at home, 80% of approved charges including equipment, supplies, support Method I—all equipment, services, and costs of supplies, services from training you and the dialysis clinicperson helping you

Method II—direct dealing with supply company for equipment and supplies

Home support 80% of approved charges—services, such as Method IIvisits to clinic for people on home Does not pay for home dialysis helper for home dialysis,

which is billed separately by the clinic

Included in Method I reimbursement to clinic

Home dialysis 80% of approved charges— Depends on drugs, such as Method II selected planerythropoeitin to treat anemia

Doctors’ services, 80% of approved chargesin the hospital and outpatient

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Dialysis-related 100% of approved chargesclinical lab tests for certain laboratory tests and X-rays are covered by the dialysis

facility’s composite rate

80% of approved charges for diagnostic tests such as EKGs and X-rays

Transplant surgery All costs after inpatient in an approved deductible amount hospital ($952 in 2006)

Doctors’ services for 80% of Medicare-approved kidney transplant amount for recipientsurgery

100% for donor

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In-hospital lab and 100%other tests needed to evaluate your medical condition and that of potential donors

Donor’s medical 100% costs, in the hospital and outpatient

Self-administered Depends on drugs for transplant selected planrecipients such as oral infection treatments and intravenous immune globulin

Immunosuppressant 80% if Medicare Part A is drugs and Non- effective the month the Immunosuppressant transplant takes place if it is drugs done in a Medicare-approved

facility. If on Medicare because of kidney failure only, coverage lasts for 36months following transplant surgery. No time limit on coverage if on Medicare due to age or other disability.

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HHooww ttoo eennrroollll iinn MMeeddiiccaarree

If you are under age 65, your firstchance to enroll in Medicare begins inthe month you begin treatment for kidneydisease and ends seven months later.This is not your last chance to enroll(See “Delaying Medicare enrollment”on page 30), but, if you wait, you canonly sign up for Medicare Part B inJanuary, February, or March in futureyears, and coverage won’t begin untilJuly 1 of that year.

People with kidney disease can enroll inMedicare at their local Social Securityoffice, or by calling 1-800-772-1213and making an appointment to enroll.Before signing up, your dialysis clinicor transplant program must complete aform and have it signed by your doctorverifying you have started dialysis orreceived a kidney transplant. To findyour local office, look for Social SecurityAdministration under United StatesGovernment listings in the Governmentpages of your phone book.

You can apply for Medicare Part Dthrough an insurance company that sellsthe plan, by calling 1-800-MEDICARE(1-800-633-4227), or by going onlineat wwwwww..mmeeddiiccaarree..ggoovv during the initialenrollment period (Nov. 15, 2005–May 31, 2006), within six months ofstarting Medicare, or between Nov. 15and Dec. 31 each year.

If you are over 65, already haveMedicare Part A, and are paying ahigher Part B premium because youdelayed enrollment when you firstbecame eligible, you should be able tolower the cost of your Part B premiumby going to your local Social Securityoffice and enrolling in Medicare basedon having kidney disease.

WWhheenn MMeeddiiccaarree bbeeggiinnss ttoo ppaayy

Medicare will not start until the first dayof your third full month of dialysis, ifyou choose in-center hemodialysis. Forexample, if you start dialysis anytime inJune, Medicare will begin to pay Sep. 1.Medicare will pay for the first threemonths of dialysis if you were alreadyon Medicare when you started dialysisor if you start a home dialysis trainingcourse at a Medicare-approved facilitywithin the first three months of treatmentand you plan to do home dialysis.

If you need a transplant and are not on dialysis, Medicare payments canstart the month you are admitted to a Medicare-approved hospital for atransplant or up to two months beforeadmittance if pre-transplant health careand testing are begun. Payments canstart two months before your transplantif it is delayed more than two monthsafter you are admitted to a hospital.This happens most often when youhave a living donor.

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DDeellaayyiinngg MMeeddiiccaarree eennrroollllmmeennttIf you have an employer group health-insurance plan, it is the “first payer” foryour medical costs for 30 months afteryou become eligible for Medicare—even if you haven’t yet enrolled inMedicare. If your plan will pay all costsover that period, you may not want topay Medicare premiums. But considerthis carefully: One possible problem isthat you may pay more for Medicare-covered services under your health-insurance plan than you would underMedicare. That’s because Medicareproviders must discount charges forpeople with Medicare. Also, delayingenrollment may affect your future cover-age for transplant drugs. If you are atransplant recipient, for example, youneed Medicare Part A coverage in effectthe month you get a transplant in orderto get coverage for transplant drugs,and you need Part B to help pay foranti-rejection drugs. You will want to beenrolled in Part A when you have thetransplant operation in order to protectyour right to get Medicare coverage if you need it for immunosuppressantdrugs for that transplant in the future, orif you become disabled and eligible forMedicare at age 65. Finally, you won’tbe able to sign up for Medicare Part Duntil you are enrolled in Medicare.

One advantage to delaying enrolling inMedicare is that you keep your optionsopen to buy a Medigap (MedicareSupplement Insurance) policy in thefuture. If you sign up for Medicare andhave health insurance through youremployer, you do not need Medigapfor the 30-month coordination period. If you want Medigap coverage afterthat, however, you may not be able toget it because you did not sign up forMedigap within six months of enrollingin Medicare. Most companies sellingMedigap policies have six-month openenrollment periods for people (usuallyage 65 and older) with pre-existingconditions such as kidney disease.Check with the health insurancecounselors at your State InsuranceDepartment to learn the requirementsfor Medigap enrollment in your state.Look under State Government in theGovernment pages of your phone bookand then Insurance. For a map withstate insurance department contacts,visit wwwwww..nnaaiicc..oorrgg.

Another advantage of delayingMedicare enrollment is that you don’trisk losing your right to COBRAcoverage. See “If you lose your job” on page 14.

(continued on page 30)

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If you decide you don’t want to sign upfor Medicare right away because youhave insurance through an employer,be sure to delay getting both MedicarePart A and Part B and enroll in Medicarebefore the end of the 30-month period.If you enroll in Part A and delay signingup for Part B, you will only be able toenroll in Part B in January, February, orMarch each year and your Medicarecoverage will not begin until July 1.

That could leave you with an expensivegap in coverage because your employerplan is no longer the primary payer.Your Part B premium also may go upabout 10 percent each year you delayenrollment.

Talk with your social worker, or planadministrator if you have health insur-ance at work, to weigh the pros andcons of delaying enrollment in Medicare.

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Pros Cons

You postpone paying Medicare premiums You will not be eligible for discounts on Medicare-for up to 30 months covered expenses and could possibly pay more for

these services under your health-insurance plan You retain your right to buy Medigap (Medicare supplement) insurance without a You will pay higher Part B premiums pre-existing condition waiting period if you when you enrollare 65 or older

You cannot sign up for Part DYou can get and keep health insurancethrough COBRA If you receive a transplant, you might not be

able to get coverage for anti-rejection drugs for many months

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If you have health insurance throughyour employer, see “How Medicareworks with your health insurance” onpage 32.

WWhheenn MMeeddiiccaarree ssttooppss ppaayyiinngg

If you have Medicare only because ofkidney failure, and not because youare 65 or older or because you aredisabled, your coverage will end 12months after you stop dialysis if yourkidney function improves, or 36 monthsafter you have a successful kidneytransplant. It will not end if you have to return to dialysis or get a kidneytransplant within those time frames.

PPaayyiinngg ffoorr ccoossttss MMeeddiiccaarree ddooeessnn’’tt ccoovveerrEven if you have Medicare, you willhave to pay some of your medicalcosts, such as 20 percent of dialysiscosts and Medicare premiums anddeductibles. Several programs can helpyou with those costs, including Medigappolicies, Medicaid, Medicare SavingsPrograms, and state kidney programs.

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A Medigap or Medicare SupplementInsurance policy, as the name suggests,fills in the “gaps” in your OriginalMedicare Plan, paying for Medicaredeductibles and coinsurance. (MedicareAdvantage Plans, previously calledMedicare + Choice, pay for more

services than Original Medicare Plans,so, if you have a Medicare AdvantagePlan when you have kidney failure, youdon’t need Medigap insurance.) SomeMedigap policies also can pay for extrahealth-care services such as annualcheckups, at-home recovery, andemergency care if you become ill on atrip outside the country. Routine dialysisis not considered an emergency, so itwill not be covered outside the UnitedStates by most Medigap plans orMedicare, but may be covered byother insurance. Check your policy forthis coverage.

Medigap policies are available fromprivate insurance companies and youwill pay a premium for them. Generally,you must have both Medicare Part A andPart B before you can buy a Medigappolicy. You may have to be at least 65.Some states require companies that sellMedigap insurance also to offer it topeople who are not yet 65, but qualifyfor Medicare. There are 10 standardMedigap polices, identified by a letterof the alphabet from A through J. (Two new plans, K and L, are plannedfor introduction in 2006.) AlthoughMedigap policies must offer the samebenefits no matter where you live(except Massachusetts, Minnesota, and Wisconsin), they do vary in cost,so be sure to look at policies fromseveral insurance companies beforebuying one. To read more aboutMedigap policies, request a free copyof the publication, Choosing a Medigap

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If you are on Medicare only because youhave kidney failure, and not becauseyou are 65 or older or previouslydisabled, Medicare coverage will notstart for three months if you get in-centerhemodialysis. If you are covered by anemployer’s group health-insurance plan,however, it may pay those costs. If youtrain for home dialysis or self-caredialysis in a clinic, Medicare paymentscan begin the month you start dialysis.Your health-insurance plan will be the“first payer” (primary coverage) onyour bills for a 30-month coordinationperiod. If it doesn’t take care of all yourcosts during this period and you signedup for Medicare, then Medicare, your“secondary payer” (secondary coverage),may pay some or all of those costs.After 30 months, the plans switchplaces. Medicare will be first payer,

paying for Medicare-covered services.Your health plan will be second payer,paying for some or all of the servicesand costs not covered by Medicareand possibly additional services thatonly your health plan covers. Talk withyour health insurance plan adminis-trator about how your plan works with Medicare and how Medicarecoordinates with your insurance. If youlose your health insurance during the“first payer” period, notify Social Securityso Medicare will take over. For moreinformation, you also can read Medicareand Other Health Benefits: Your Guideto Who Pays First, Publication No.CMS-02179. Go to wwwwww..mmeeddiiccaarree..ggoovv,click Find a Medicare Publication, and then type the publication name or number in the box shown.

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Policy: A Guide to Health Insurance for People with Medicare, Publica-tion No. CMS-02110, by calling 1-800-MEDICARE (1-800-633-4227).This publication is available online atwwwwww..mmeeddiiccaarree..ggoovv under Search Tools.Click Find a Medicare Publication andtype in the publication name or numberin the box shown. You also can talkwith a Medicare representative aboutMedigap policies available in your state.Your State Health Insurance AssistanceProgram (SHIP) or State Insurance

Department can give you informationabout Medigap policies for people with kidney failure. Look under StateGovernment in the Government pagesof your phone book and then Insuranceor go to wwwwww..sshhiippttaallkk..oorrgg and clickFind a State SHIP. You can find Medigappolicies online listed by state, too.

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Medicaid helps pay medical costs forpeople with low income and little savings.Medicaid can pay your Medicare

premiums, deductibles, coinsurance,and some costs Medicare doesn’t cover,such as transportation to dialysis insome cases. To be eligible, you musthave Medicare Part A, monthly incomebelow a specific amount, and savingsof less than a specific amount. If yourincome is above the minimum, you stillmay qualify if you have high medicalbills. To find out if you can get Medicaid,call 1-800-MEDICARE (1-800-633-4227)and ask for information on MedicareSavings Programs. You also can contact your state Medicaid office.Look under State Government in theGovernment pages of your phone book and then Medicaid, or go towwwwww..ccmmss..hhhhss..ggoovv//MMeeddiiccaaiidd. StateMedicaid programs also help peoplewith lower income and limited savingswho don’t qualify for Medicare.

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If your income or savings is too high foryou to be eligible for Medicaid, youare eligible for Medicare Part A andPart B, and you need help payingMedicare premiums, deductibles, andcoinsurance on covered services, oneof these Medicare Savings Programsmay provide help. Each program hasits own income limits (based on theFederal Poverty Level, or FPL), andsome states use different limits.

• Qualified Medicare Beneficiary,which pays Medicare Part A andPart B premiums, deductibles, andcoinsurance.

• Specified Low-Income MedicareBeneficiary, which pays MedicarePart B premiums.

• Qualified Individual 1, which payspart of Part B premiums for a limitednumber of lower income people ineach state.

• Qualified Disabled Working Individual,which can pay your Medicare Part Apremiums if you had Social Securityand Medicare because of kidneydisease, but lost your Social Securitybenefits and free Medicare Part Abecause you returned to work andnow earn more than the amountallowed. You must be disabled andhave no other way to get MedicarePart A, such as a worker’s spouse. If you get Part A, you can get andpay the premium for Part B.

To find out if you qualify for any ofthese savings programs, contact yourState Medicaid Office or MedicalAssistance Office. For phone numbers,go online to wwwwww..mmeeddiiccaarree..ggoovv andclick Find Helpful Phone Numbers andWeb sites. You also can call 1-800-MEDICARE (1-800-633-4227) and askfor information on Medicare SavingsPrograms. For the current year’s FPLguidelines, go to wwwwww..aassppee..hhhhss..ggoovv//ppoovveerrttyy and click HHS Poverty Guidelines.

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Use this worksheet to keep track of the names and numbers of people you talk with, dates you talk with them, and the advice they give about how you can get benefits from these programs.

Medicare Name & Number Date Notes

______________________________ __________ __________________________________

______________________________ __________ __________________________________

______________________________ __________ __________________________________

______________________________ __________ __________________________________

Medigap Name & Number Date Notes

______________________________ __________ __________________________________

______________________________ __________ __________________________________

______________________________ __________ __________________________________

______________________________ __________ __________________________________

Medicaid Name & Number Date Notes

______________________________ __________ __________________________________

______________________________ __________ __________________________________

______________________________ __________ __________________________________

______________________________ __________ __________________________________

Medicare Savings Programs Name & Number Date Notes

______________________________ __________ __________________________________

______________________________ __________ __________________________________

______________________________ __________ __________________________________

______________________________ __________ __________________________________

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“After 25 years with CKD, I believethe biggest financial challenge iskeeping up with the annual costincreases for both healthinsurance and prescription drugs.My advice is to develop a goodrelationship with yourpharmacist. Your first step? Gotell your pharmacist you

Fred Manfred, Jr.Fred Manfred, Jr.

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