Part Two: What Kidney Patients Should Know about Medicare

April 7, 2016

The following post is part two of a two-part series from Matthew Bahr, who has more than 10 years of experience in the healthcare finance field. You can learn more from him on his website, The Patient Financial Advisor. As always, if you have specific questions about your personal coverage or your transplant-related expenses, please contact an insurance representative or a transplant financial coordinator or social worker at your transplant center.

If you didn’t catch part one of this two part series on Medicare and ESRD, check out part one here. I would recommend you read that first before diving into this article.

The reason for that is two-fold:

  • Part two covers specific situations you will encounter only after you have received Medicare due to ESRD.
  • You will need to apply information you learned from part one in sections of part two

Now with that little disclaimer out of the way, let’s take a look at today’s topics of discussion. They include coordination of benefits, which I will explain what that is if you haven’t heard the term before, and immunosuppressant medication benefits under Part B. If you are currently on a transplant waiting list, please be sure you review the section on immunosuppressant drugs as it will have information that benefits you and will help you plan for the future.

Coordination of Benefits
Let me preface this section by stating that this can be confusing. But try your best to be patient, it will eventually click. Good news is that if you are on a transplant list, your Financial Coordinator will be able to assist you if you need additional help. If you are not on a transplant list but go to a dialysis center, the Social Worker at the center will be able to assist as well.

Plus, you got me! And I don’t know how to put this, but I’m kind of a big deal.

All kidding aside, my goal is to explain what you need to know in a way that's easy to understand and sticks with you.

So, first things first, let's define what "coordination of benefits" mean.

Coordination of benefits or COB, is the process in determining which insurance pays primary, secondary, tertiary, etc. You’re not allowed to choose which insurance you want to bill as primary or secondary, there are rules that need followed and that is certainly true when Medicare is involved. Here are the Medicare COB rules when you’re eligible due to ESRD.

  • If you have group health coverage through an employer, Medicare will be the secondary payer once you are eligible due to ESRD. 
    If you had no coverage prior, then Medicare will become your primary insurance
  • The COB stays like this for a period of 30 months. On the 31st month, the COB flips. Medicare will become primary and the group health plan will drop down to secondary.

To demonstrate how this works, let's create an example.

Let’s say you work full time and have health insurance, BCBS AZ, through your employer. Now imagine you’re told you need to start hemodialysis on 12/1/2015. When would you be eligible for Medicare? For hemodialysis, we know you have to be on a regular course for 3 months and then the 4th month you become eligible. So, December, January, February would be our 3 month period, which now makes you Medicare eligible on 3/1/2016. Since you have BCBS AZ through your employer, your BCBS AZ plan will be the primary payer and Medicare will be secondary payer for 30 months. That 30 month coordination period begins when you first become eligible for Medicare, meaning 3/1/2016. 30 months later is 8/31/2018, which would make Medicare primary and BCBS AZ secondary on 9/1/2018.
Easy, right? (kidding!)

BUT, as with many things in life, there are exceptions to the rules. Here are a couple big ones:

  1. If you had Medicaid insurance only before you became eligible for Medicare due to ESRD, once your Medicare becomes effective, it will become the primary payer. Medicaid is ALWAYS the payer of last resort.
  2. If you had an individual policy prior to becoming eligible for Medicare, your Medicare may become primary over your individual plan once it becomes effective. Your best bet is to contact the individual policy's member services department to confirm how they'll coordinate with Medicare.

Immunosuppressive Drugs
This is the last section I want to review with you today. Hopefully your eyes haven't glazed over yet, so before they do, let's review how Medicare could cover these medications for you at 80%.

In order to have this benefit, you must meet these specific requirements,

  • If you are entitled to Part A at time of your transplant AND Medicare paid for your transplant in a Medicare approved facility

or

  • Medicare was secondary payer but made no payment

If you satisfy one of these requirements above, your immunosuppressive drugs will be covered by your Medicare Part B at 80%. You would be responsible for the remaining 20%.

If you do NOT meet either one of these requirements, then your immunosuppressive drugs will be covered by your Medicare Part D. These costs will vary by plan, but Part D will also cover any drugs you may need for other medical conditions.

This information is good to know for potential transplant patients. Often I meet with patients asking if they should sign up for Medicare after their kidney transplant. I always advise that they should at least get Part A in place so they are qualified for this benefit.

In closing, I know what I have shared today is probably overwhelming. What makes understanding all of these rules with Medicare and ESRD even more complicated is that all of this usually plays out over the course of multiple years. When you have that long of a time period, there are many variables that will come into play.

What I would recommend is to only read the sections that currently apply to you. For example, if you recently started dialysis, I would review the eligibility sections in part one first so you understand when you would become Medicare eligible. Once you have that down, or if your Medicare coverage was already active, take a look at the COB section to get familiar with the 30 month rule and how to determine who is the primary payer.

I don't think it would be a terrible idea to print this post or mark it as a favorite. That way you can refer back to it as you start approaching different phases of your dialysis and transplant journey.

Lastly, please remember, this post should be used as a guide only.

ALWAYS, I mean ALWAYS, contact your own insurance plan for final determinations. (You can do this by calling the member services number on the back of your card.)

Until next time, good vibes always.

Matthew