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A Note on the History of ESRD Medicare

A Note on the History of ESRD Medicare - Patient Resources, Social Work Services Quick Guide, Social Work Manual, Population Specific, Transplant, Kidney Transplant, Financial



Email from Beth Witten, sent to CNSW ListServ

Medicare is not forced down patients’ throats. It’s a benefit that many patients have earned through work (theirs, spouse, or parent if a child).

Medicare was extended to patients with ESRD because those with ESRD and their loved ones and organizations like the NKF fought to get the Social Security law amended in 1972 to cover those with ESRD so they could afford the expensive treatment.

Prior to that patients had to have EGHP coverage or sufficient funds to pay for treatment or they died.

Originally Medicare was always paid primary. Then to save money in Medicare money, Medicare started paying second to employer group health plans.

The MSP period was initially only 12 months and only applied to those with ESRD as their only reason for eligibility, then it was extended to 18 months and finally the first 30 months of Medicare eligibility for ESRD patients including those who have ESRD and are eligible for Medicare due to age or disability.

After the MSP ends, Medicare will pay primary for those who have Medicare.

Why would any insurance company willingly choose to continue to cover anyone for whom Medicare could be their primary payer after the MSP period?

If an insurance company chooses only to pay secondary benefits because federal law allows it to become the secondary payer at the end of the MSP period, patients can choose to enroll in Medicare and it will be the primary payer as long as a patient is on dialysis and for 36 months after transplant if the patient has no other reason for Medicare eligibility.

The key is that if the patient chooses to delay enrollment in Medicare, he/she has to understand the consequences.

  1. Patients can waive Part A and Part B to be able to enroll in Medicare any time
  2. Patients can withdraw from Part A and/or Part B; those who have received SSDI checks for 24 months can’t disenroll from Part A as that’s part of the SSDI “package”
  3. Without Part B coverage, providers can charge EGHP deductibles and coinsurance; however, if the patient has Part B, providers that accept Medicare assignment must write off any balance they would bill the patient that’s over 100% of the Medicare allowed charge
  4. Patients who take Part A (free) and waive Part B can only enroll in Part B during the general enrollment period with Medicare Part B starting in July, meaning keeping track of dates is important to avoid a gap in primary coverage
  5. If there is a change in her (or his) job that limits coverage she might be able to get COBRA at a much higher premium if the company is required to provide it
  6. If her plan changes to restrict what providers are covered, unless she’s waived both Part A and B she will be limited on when she can enroll in Medicare and when it will take effect to pay for services at those providers (see #4)