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ESRD Patients that Have Marketplace Coverage

ESRD Patients that Have Marketplace Coverage - Patient Resources, Social Work Services Quick Guide, Social Work Manual, Population Specific, Transplant, Kidney Transplant, Financial



An ESRD patient who had an individual marketplace/exchange plan before they had ESRD can keep that coverage and any tax credits and subsidies they were getting as long as they do not enroll in Medicare. The IRS issued notice in August that clarified that this is the case. However, once a patient enrolls in Medicare they lose any subsidization and premium tax credits. They can keep that plan and pay for it on their own, but given it's an individual plan there is no coordination period like group health plans have. Whether the plan will pay any costs Medicare doesn't cover will depend on the policy language of the plan the patient picks, but I expect any secondary payment to be unlikely.

In some situations patients may be better off keeping their Marketplace plan if they are receiving tax credits and subsidies, but there are still a lot of unknowns that we are working on with HHS and the IRS. One unknown is if the patient will have to pay a late enrollment penalty if they forgo Medicare and then later decide to enroll. This is only one of the many questions still out there, but we are working to get answers and create helpful information for you all to help patients make the best decisions.

If a dialysis patient already has Medicare they cannot purchase a plan through the Marketplace and even if they could it is unlikely to coordinate with Medicare.

Again we will have a webinar on October 30th to discuss more of this. Someone should be sending out more details about that soon. However, as you have questions please email me tonya.saffer@kidney.org because I don't always get to check the listserv daily.


Tonya Saffer, MPH

Senior Federal Health Policy Director

National Kidney Foundation

January 24, 2014

I have one caveat. Recently CMS ruled that if someone was receiving Medicare supplemental coverage under their state’s preexisting condition insurance program (PCIP) and was told their plans were going to be canceled they may be able to get coverage in the individual market. CMS will temporarily (through Dec 31, 2015) not enforce prohibition of private plans to sell policies to Medicare beneficiaries under 65 who have experienced the loss of their supplemental coverage due to the discontinuation of PCIP. The idea is that this gives states an extra year to develop a solution to finding those individuals supplemental coverage.

More info: http://www.cms.gov/Medicare/Health-Plans/Medigap/Downloads/Sale-of-Individual-Market-Policies-to-Certain-Medicare-Beneficiaries.pdf


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