2019 - Health Insurance 101: Options for People with ESRD

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on March 14th, 2019.
2019 - Health Insurance 101: Options for People with ESRD

Dialysis clinic staff are often called upon to help people make choices about how to pay for dialysis. Kidney disease is costly, but for US citizens and those in the US legally, there are multiple payment options. People with kidney disease must look for a plan that will cover hospital stays, doctors and other providers, in-center and/or home dialysis and transplant (including living donors), equipment and supplies, and drugs. They need to plan for changes as they move from decreased kidney function to kidney failure, and to or from dialysis or transplant. And, there may be different things to weigh with a health plan sponsored by an employer or union.

The table below addresses some common questions and compares Original Medicare, Medicare Advantage, and qualified health plans (QHPs) sold on a state or federal Marketplace or by an insurance company. QHPs meet requirements of the Affordable Care Act (ACA, or “Obamacare”).

NOTE: This table does not include short-term insurance plans or association plans that have lower premiums and can only be renewed once a year for up to 3 years. These plans can deny coverage for preexisting conditions and charge more for older people and women. They can exclude coverage for drugs, mental health, maternity, and substance abuse treatment and can set annual or lifetime benefit caps. Some have referred to these plans as “junk insurance.”

WHO is eligible?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • Citizen or legally present for >5 years

  • Age 65 or older

  • Receiving SSDI for >2 years

  • Have ESRD requiring dialysis or transplant

  • Citizen or legally present in US >5 years

  • Live in plan’s area

  • If on dialysis, can enroll only in a Special Needs Plan (SNP) accepting ESRD (limited plans); 1/2021 will be able to enroll in any MA plan

  • If transplanted: not on dialysis can enroll in any MA plan

  • Citizen or legally present and not incarcerated

  • Can’t join if have Medicare Part A and/or Part B, full Medicaid or CHIP

  • Can keep after enrolling in Medicare, but lose tax credits and subsidies; individual plans don’t pay Medicare out-of-pocket costs

WHEN can a person with ESRD enroll?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • Initial Enrollment Period (IEP): 7 mo period starting 3 mo. before eligible mo. through 3 mo. after eligible mo.

  • General Enrollment Period (GEP): If Part A was taken alone at first, can only apply for Part B 1/1-3/31 each year & Part B takes effect July 1st

  • Dialysis patients are NOT eligible for a Special Enrollment Period (SEP) to enroll late in Part B after taking Part A so must wait for the GEP.

  • Initial Coverage Enrollment Period: same as Original Medicare

  • Open Enrollment Period: Join or switch health/drug plans each year from 10/15-12/7 for a plan that starts on Jan. 1

  • MA Disenrollment Period: switch from an MA plan to Original Medicare & enroll in a Part D plan 1/1-2/14; before switching, have a plan for how to pay Original Medicare out-of-pocket costs.

  • Yearly 11/1-12/15

  • Special Enrollment: Limited time to enroll if household or residence changes, other health coverage is lost, and some less common events

WHAT happens if a person enrolls late?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • For failure to enroll in Part B after taking Part A during the IEP, the Part B premium penalty is 10% per year of delay

  • Can only enroll in Part B during the general enrollment period (1/1-3/31) with Part B starting in July; could have gap in coverage

  • MA plans include Part A & B automatically—but not all include Part D (if not, buy a Part D plan)

  • May keep ACA QHP plan but…

  • There is a premium penalty if delay enrolling in Medicare beyond IEP

WHEN will the plan take effect?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • There is a 3 month wait for Part A & B unless someone starts home training or gets a transplant during those 3 months. Then Medicare backdates to the 1st month of dialysis or pre-emptive transplant.

  • Medicare may backdate up to 2 months before a transplant to cover a patient’s admission for evaluation

  • Same as Original Medicare

  • Apply 11/1-12/15, & plan starts Jan. 1

  • With a special enrollment period, coverage starts the month after enrollment

What are the TYPES of coverage?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • Part A: Hospital (inpatient, rehab, skilled nursing, hospice, recipient & donor’s transplant surgery, etc.)

  • Part B: Medical (outpatient, doctors, dialysis, some dialysis-related drugs & anti-rejection drugs)

  • No coverage for most dental, vision, hearing

  • Providers that accept Medicare assignment cannot balance bill those with Medicare for charges more than 100% of what Medicare allows

  • Structure: HMOs, PPOs, Private Fee for Service, Special Needs Plans, HMO Point of Service, Medical Savings Accounts

  • Includes Parts A & B, and may cover drugs on formulary, and other services not covered by Original Medicare like vision, dental, hearing, exercise

  • Care Network may be more limited than Original Medicare

  • Bronze

  • Silver (option for those needing subsidies to pay out-of-pocket costs)

  • Gold

  • Platinum

  • Catastrophic plan, for <30-years old & those who have a plan cancel, hardship or affordability exemption; lowest premium, highest deductible, may limit number of visits and providers

What is the PREMIUM in 2019?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • Part A: Free with enough work credits based on age (ask Social Security)

  • Part A: Free If 65 or older with too few work credits, can buy Part A for $437/mo with <30 credits or $240/mo with 30-39 credits

  • Part B: $135.50/mo, or more if income is >$80K single/$160K couple

  • State may pay A&B premiums if someone qualifies for certain Medicare savings programs

  • Varies with plan. Plans with lower premiums may have higher out-of-pocket costs

  • Varies with plan. Plans with lower premiums may have higher out-of-pocket costs

What are other possible OUT-OF-POCKET COSTS in 2019?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)

Part A (hospital):

  • Days 1-60: $1,346 deductible, no copay

  • Days 61-90: copay $341 per day

  • NOTE: Get back days 1-90 if out of hospital 60 days

  • Days 91-150 (lifetime reserve days once used they’re gone): copay $682/day

  • Day 151 on: all costs

Part B (medical):

  • Deductible: $185/year

  • Coinsurance: 20% of allowed charge (with no maximum)

  • Out-of-pocked maximum up to $6,700/year for an individual for Part A and B covered benefits; a few plans have lower caps

  • Out-of-pocket maximum $7,900/year/ for an individual plan or $15,800/year for a family plan

  • Bronze: pays average of 60%;

  • Silver: pays average of 70%

  • Gold: pays average of 80%

  • Platinum: pays average of 90%

  • Catastrophic: pays average of <60% of cost of care for <30 years old or those with a hardship exemption

HOW can out-of-pocket costs be paid?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • Medigap plans pay all or most out-of-pocket costs for Medicare-covered services; some states have no Medigap plans for those <65 or with ESRD

  • Full Medicaid, if qualify: pays Medicare out-of-pocket costs

  • Medically Needy Medicaid (not in all states): pays costs over “spenddown” (like a deductible)

  • Medicare Savings Programs, if qualify: QMB, SLMB, QWDI pay Part A and/or B premiums, QMB pays Medicare out-of-pocket costs too

  • Other health insurance plan: employer or union health plan, private plan off the marketplace pays as per policy

  • Medicaid if eligible

  • Cannot use Medigap

  • There are Special Needs Plans (SNPs) for those with both Medicare & Medicaid

  • Income of 100-400% of the federal poverty level may qualify for a premium tax credit

  • Income of 100-138% of the federal poverty level (some states allow higher income) may qualify for lower out-of-pocket costs (Silver plan)

  • No premium tax credits or cost saving subsidies if income is <100% of federal poverty

What are the options for DRUG coverage?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • Medicare Bundle: Some ESRD-related drugs are covered under the rate paid for dialysis

  • Part B covers some drugs, including anti-rejection IF Part A was in effect the transplant month; Part B will never cover anti-rejection drugs if Part A was not in effect the transplant month; if not, Part D covers

  • Part D: Private companies sell these plans; have lists of covered drugs & costs vary from plan-to-plan and drug-to-drug

  • State Pharmacy Assistance Programs (where offered) can help

  • State kidney programs (if available) may help

  • Drugs are often covered in MA plans; anti-rejection covered under Part B or D depending on whether patient had Part A the transplant month; other drug copays vary

  • If MA plan has no drug coverage, may buy a Part D plan; covered drugs & costs vary

  • State Pharmacy Assistance Programs (where offered) may coordinate with MA drug plan differently from Original Medicare

  • Drugs are included in the basic benefit

  • Formulary & costs vary

  • A transplant recipient may want to review these plans if after 36 months post-transplant & Medicare ends & not eligible for another plan, not age 65 or older and not disabled for another reason.

WHEN is drug plan enrollment?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • Initial Enrollment Period (IEP) is the same as the 7 mo. Part A and/or B IEP. IEP. If Medicare is backdated, IEP start is based on the Medicare award letter date.

  • If you have an employer group health plan, ask if enrolling in Part D will affect your employer plan’s health or drug coverage

  • Yearly: 10/15-12/7

  • Medicaid, those receiving “extra help” due to limited income or in nursing homes can switch once/quarter. The new plan starts the next month.

  • Initial Enrollment Period Same as Original Medicare

  • Ask if enrolling in separate Part D plan will affect your employer plan’s health or drug coverage.

  • Special Enrollment Period: when a person switches from Original Medicare to MA, from MA to Original Medicare, or from one MA plan to another

  • No separate enrollment; drug coverage is included in individual QHPs and Small Business Health Options Program (SHOP) plans sold on the Marketplace)

  • Drug coverage may not be as good as Medicare Part D. Each year, the plan must tell members whether the drug plan pays as well as Part D

How do benefits COORDINATE WITH employer or union plans?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • Can have Original Medicare with a union/employer plan

  • Employer plan pays 1st for 30 months from 1st mo. eligible for Medicare. Providers who agree to accept Medicare allowed payment cannot bill you for unpaid balances over that amount.

  • After 30 months, Medicare pays 1st and union or employer plans pay 2nd. As a secondary payer, union or employer plans may have out-of-pocket costs.

  • Some employers/unions may enroll their Medicare employees in a group MA plan or an individual MA plan.

  • Someone who gives up an employer or union plan may not get it back

  • Employers with ≤50 full-time employees may provide a Marketplace plan & dental plan through SHOP

  • If someone has Medicare & a SHOP plan, payment follows Medicare secondary payer rules like Original Medicare

How does a patient’s WORK affect plan?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • People on dialysis can work & keep Medicare (see section on coordination of benefits)

  • Employer plans pay first for transplant recipients on Medicare due to disability after ESRD benefit ends at 36 mo. post-transplant if plan is based on own or family’s current work & employer has ≥100 employees

  • Employer plans pay first for transplant recipients on Medicare due to age after ESRD benefit ends at 36 mo. post-transplant if plan is based on own or family’s current work & employer has ≥20 employees

  • Same as Original Medicare

  • If eligible for a SHOP plan the premium can’t be more than 9.86% of the employee’s income to be considered “affordable.” If not affordable, person can choose to enroll in a QHP instead to get premium tax credits and subsidies, if eligible.

How LONG will the plan last?
Original Medicare Medicare Advantage (MA) ACA Qualified Health Plan (QHP)
  • ≥65: as long as premiums are paid

  • On dialysis: as long as dialysis continues

  • As long as SSDI checks continue

  • Kidney function improves (dialysis not needed): 12 mo

  • Transplant: 36 mo.

  • Continuation of Medicare”: 93 mo after trial work period ends if disabled

  • “Medicare for People with Disabilities Who Work”: after 93 mo pay Part A, B, & D premiums to keep Medicare

  • Section 301” can help transplant patient who is in a VR or other program whose goal is to end benefits when SSA says s/he has medically improved; s/he keeps SSI & Medicaid or SSDI & Medicare until program ends, s/he leaves the program, or SSA decides the program is unlikely to prevent return to disability rolls.

NOTE: If SSDI ends before 36 months after transplant, Part B premium won’t be paid with SSDI, so prepare to pay premium another way to keep Medicare

  • Same as Original Medicare

  • As long as the premium is paid or until the plan is cancelled

  • Can switch plans during open enrollment annually

Helpful Resources:

Comments

  • Mary Beth Callahan

    Mar 21, 2019 8:18 AM

    I think this is very helpful. Thank you for pulling the info together.

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