Medicare Entitlement Because of a Disability

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2004 REACH National Medicare Training Program
Speaker Name Group Name Date
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Medicare Entitlement Because of ESRD or Disability

• Module 6

3
Medicare for People withEnd-Stage Renal Disease

• Module 6
• Lesson A

4
Session Topics

• Overview
• Eligibility and enrollment
• Coverage
• Health plan options
• Information sources

5
Session Topics

• Overview
• Eligibility and enrollment
• Coverage
• Health plan options
• Information sources

6
End-Stage Renal Disease
Overview

• Often referred to as ESRD
• Kidney impairment
• Appears irreversible and permanent
• Requires regular dialysis or a kidney transplant
  to maintain life

7
Medicare for People with ESRD
Overview

• Coverage began in 1973
• Over 1 million received life-saving therapy
• Dialysis
• Transplant
• Over 350,000 receiving therapy
• 90,000 had successful kidney transplant
• 20,000 improved so much they left Medicare

8
Session Topics

• Overview
• Eligibility and enrollment
• Coverage
• Health plan options
• Information sources

9
Part A Eligibility Requirements
Eligibility and Enrollment

• Eligible for Medicare Part A at any age if
• Regular dialysis or
• Kidney transplant
• AND at least one of the following
• Worked required amount of time
• Receiving SSA or RRB cash benefits
• Spouse or dependent child of someone who worked
  required amount of time

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Part B Eligibility
Eligibility and Enrollment

• If entitled to Medicare Part A
• Can enroll in Part B
• Will have to pay Part B premium
• Will need both Part A and Part B to cover certain
  services
• For more information
• Call SSA at 1-800-772-1213
• Call RRB at 1-800-808-0772

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Enrollment
Eligibility and Enrollment

• Enroll at local SSA office
• May delay enrollment if covered by GHP
• Get the facts before deciding to delay
• Especially if transplant is planned
• If already enrolled in Part A
• May eliminate Part B surcharge

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30-Month Coordination Period
Eligibility and Enrollment

• During coordination period
• GHP pays first
• Medicare pays second
• Begins when eligibility or entitlement begins
• Even if not enrolled in Medicare
• Medicare pays first after 30 months
• New 30-month period begins if new period of
  Medicare coverage

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Enrollment Decision
Eligibility and Enrollment

• Can delay enrollment in Medicare (Part A and Part
  B)
• Considerations in delaying
• Medicare could help pay deductibles and
  coinsurance
• No Part B premium if you delay enrollment
• Immunosuppressive drug therapy is covered
• If you were entitled to Part A at time of
  transplant and Medicare made payment for
  transplant OR
• If Medicare made no payment, Medicare was
  secondary payer, AND you are enrolled in Part B
  at time of drug therapy
• For as long as you have Medicare

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ESRD Coverage Begins
Eligibility and Enrollment

• Third month after the month dialysis begins
• First month if certain conditions are met
• Month you receive a kidney transplant
• Month you are admitted to approved hospital
• For transplant or procedures preliminary to
  transplant
• 2 months before month of transplant
• If transplant is delayed more than 2 months

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Coverage Ends
Eligibility and Enrollment

• If ESRD is the ONLY reason you were entitled
• 12 months after month you no longer require
  maintenance dialysis
• OR
• 36 months after month of kidney transplant

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Coverage Continues or Resumes
Eligibility and Enrollment

• If dialysis is resumed
• OR
• Another transplant is received

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Lets see what we know

• Your 30-month coordination period begins when
  your eligibility or entitlement begins, even if
  you are not enrolled in Medicare.
• True or False?

18
Here is a case study

• Brad is 59 and is entitled to Medicare based on
  ESRD. He began dialysis 3 months ago, so he
  believes his Medicare coverage will begin in his
  fourth month of dialysis. Is he correct? Are
  there situations when it would begin earlier?

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Session Topics

• Overview
• Eligibility and enrollment
• Coverage
• Dialysis patients
• Transplant patients
• Health plan options
• Information sources

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Benefits
Coverage

• All services covered by Original Medicare
• Medicare Part A
• Medicare Part B
• Special services for
• Dialysis patient
• Transplant patient
• Including immunosuppressive drugs
• Certain conditions must be met

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Covered Services
Coverage for Dialysis Patients

• Inpatient dialysis treatments
• Home dialysis training
• Self-dialysis training
• Home dialysis equipment and supplies
• Certain home support services
• Certain drugs for home dialysis

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Ambulance Services
Coverage for Dialysis Patients

• Transportation to dialysis facility
• Covered only if other forms of transportation
  would be harmful to your health
• Ambulance supplier must get written order
• For information
• 1-800-MEDICARE (1-800-633-4227)
• TTY/TDD 1-877-486-2048

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Home Dialysis
Coverage for Dialysis Patients

• Types of dialysis that can be performed at home
• Hemodialysis
• Peritoneal dialysis
• Most common drugs covered by Medicare
• Heparin
• Antidote for heparin when necessary
• Topical anesthetics
• Epogen or Epoetin alfa

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Services NOT Covered
Coverage for Dialysis Patients

• Paid dialysis aides
• Lost pay
• Place to stay during your treatment
• Blood for home dialysis
• Unless part of doctors service or needed to
  prime the dialysis equipment
• Transportation to the dialysis facility
• Except in special cases

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Medicare Part A
Coverage for Transplant Patients

• Covers inpatient hospital services for kidney
  transplant
• Transplant
• Preparation for transplant
• Kidney Registry fee
• Laboratory tests
• Full cost of care for donor
• Including care needed due to complications

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Medicare Part B for Kidney Transplant
Coverage for Transplant Patients

• Surgeons services
• Doctors services to donor
• No deductible
• Immunosuppressive drug therapy
• If entitled to Part A at time of transplant and
• Medicare paid for transplant OR
• Medicare made no payment but was secondary payer

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Coverage for Blood
Coverage for Transplant Patients

• Part A and Part B can help pay for
• Whole blood
• Units of packed red blood cells
• Blood components
• Cost of blood processing and administration
• Part A and/or Part B deductible must be met

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Immunosuppressive Drugs
Coverage for Transplant Patients

• Used to reduce the risk of rejection
• Taken for the rest of your life
• No time limit if eligible for Medicare because of
  age or disability
• Must have Part B at time of dispensing of drug

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Immunosuppressive Drugs
Coverage for Transplant Patients

• If you have Medicare only because of ESRD,
  Medicare will pay for immunosuppressive drug
  therapy if
• You were entitled to Part A at time of transplant
  and
• Medicare paid for the transplant OR
• If Medicare made no payment, Medicare was
  secondary payer
• AND
• You are enrolled in Part B at time of drug therapy

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Lets see what we know

• Which service is covered by Medicare?
• Paid dialysis aides
• Lost pay
• Kidney Registry fee

31
Lets look at a case study

• Jeff is 48 years old and just applied for
  Medicare based on ESRD. He knows that he will
  probably need a kidney transplant in the near
  future. He decided to apply for Medicare now
  because he knows that Medicare will pay for his
  immunosuppressive drug therapy as long as he is
  covered by Medicare. Is he correct?
• What are some important points for someone who
  may be having an organ transplant?

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Session Topics

• Overview
• Eligibility and enrollment
• Coverage
• Health plan options
• Information sources

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Original Medicare
Health Plan Options

• Usually the only choice
• Always an option

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Medicare Advantage Plans
Health Plan Options

• Usually not an option for those with ESRD
• May stay in a plan if already in
• May be able to join after kidney transplant
• May join another if your plan leaves
• May age in

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If Your Plan Leaves Medicare
Health Plan Options

• You have options
• Can return to the Original Medicare Plan
• Can join another Medicare Advantage plan if
  available in your area
• If your plan left on or after December 31, 1998

36
Lets see what we know

• People with Medicare who are entitled because of
  ESRD can receive both Part A and Part B services.
• True or False?

37
Lets look at a case study

• Rachel is 43 years old and was diagnosed with
  ESRD 8 months ago. She has looked at some
  marketing materials from a Medicare Managed Care
  plan and would like to join. Can she join?
  Discuss the situations where she would be able to
  join.

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Session Topics

• Overview
• Eligibility and enrollment
• Coverage
• Health plan options
• Information sources

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ESRD Networks
Information Sources

• Ensure administration of ESRD benefits
• Develop quality standards
• Assess treatment modalities
• Provide technical assistance to dialysis
  facilities
• Educate beneficiaries
• Contact information Local phone number

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ESRD Information Sources
Information Sources

• American Association of Kidney Patients
• 1-800-749-2257
• National Kidney Foundation
• 1-800-622-9010
• American Kidney Fund
• 1-800-638-8299

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www.medicare.gov
Information Sources

• Dialysis Facility Compare
• Searchable database
• Facility location
• Treatment choices offered
• Ownership
• Availability of evening services
• Quality measures

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www.medicare.gov
Information Sources

• Quality measures for dialysis facilities
• How well facility treats patients
• Getting the best possible results
• Some quality measures
• Percent of patients adequately dialyzed
• Percent whose anemia is adequately managed
• Patient survival information

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Key Concepts

• Most people with ESRD are eligible for Medicare
• It is important to understand enrollment options
• People with ESRD receive
• All Part A and Part B services
• Some additional services
• Original Medicare Plan is usually only choice
• More information is available

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Medicare EntitlementBecause of a Disability

• Module 6
• Lesson B

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Session Topics

• Overview
• Eligibility and enrollment
• Health plan choices
• Information sources

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Session Topics

• Overview
• Eligibility and enrollment
• Health plan choices
• Information sources

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Coverage for Disabled Beneficiaries
Overview

• Coverage began in 1973
• 1.7 million beneficiaries initially
• 5.6 million in 2001
• 14 of all Medicare beneficiaries

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Medicare Enrollment Trend
Overview
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Social Security and Medicare
Overview

• Relationship between Social Security and Medicare
• Medicare is title XVIII of SS Act
• Medicare based on entitlement to SS benefits
• Amendments expanded Medicare to cover
• Disabled persons under 65 entitled to SS benefits
  for 24 months

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Disability Defined
Overview

• Social Security definition
• Inability to work
• Will last for 1 year or result in death
• Can be the result of blindness
• Visual acuity 20/200 or less with correcting lens
  in better eye
• OR
• Visual field of 20 degrees or less

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Session Topics

• Overview
• Eligibility and enrollment
• Enrollment process
• Health plan choices
• Information sources

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SSA Programs
Eligibility and Enrollment

• RSDI
• Based on covered earnings
• Funded by FICA
• SSI
• Based on need
• Funded by general revenues
• Both pay benefits for people with disabilities

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Qualifying for Medicare
Eligibility and Enrollment

• Usually begins after 24 months of benefits
• Exceptions
• Begins first month for ALS
• No 5-month waiting period for cash benefits
• Childhood disability beneficiaries
• Some people previously entitled to disability
  benefits

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Qualifying for Disability Benefits
Eligibility and Enrollment

• Meet requirements for SSA disability benefits
• 5-month waiting period before cash benefits begin

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Applying for Disability Benefits
Eligibility and Enrollment

• Take your
• Social Security Number
• Proof of age
• Medical care provider information
• Medical treatment information
• Medical records, if available
• Work history information
• Most recent W-2 or self-employment tax return

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Enrollment in Medicare
Eligibility and Enrollment

• Automatic enrollment in Original Medicare
• After 24 months of disability payments
• Except for ALS
• Will receive card by mail
• Call SSA if it doesnt arrive
• Decide on Part B

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Continuing Medicare Entitlement
Eligibility and Enrollment

• Ends when SSA determines you are no longer
  disabled
• Continues for working beneficiaries who are still
  disabled
• 8½ years premium-free Part A
• May purchase coverage afterward
• Entitlement reason changes at age 65

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Lets see what we have learned...

• Most people who are receiving cash benefits for a
  disability are eligible for Medicare after 24
  months.
• True or False?

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Here is a case study

• Ramon has been told that he meets the Social
  Security definition for blindness. He knows he
  needs to apply for disability benefits, but he
  does not have all the documents he might need.
  Should he apply anyway?

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Session Topics

• Overview
• Eligibility and enrollment
• Health plan choices
• Information sources

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Choices
Health Plan Choices

• All Medicare plans available
• Original Medicare Plan
• Medicare Advantage plans
• Medicare Managed Care plans
• Private Fee-for-Service plans
• Some restrictions on eligibility for Medigap

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Coverage
Health Plan Choices

• Coverage same as for people 65 and over
• All Medicare covered benefits
• No special limitations

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Session Topics

• Overview
• Eligibility and enrollment
• Health plan choices
• Information sources

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If You Want to Know More
Information Sources

• SSA 1-800-772-1213 (TTY 1-800-325-0778)
• 1-800-MEDICARE (TTY 1-877-486-2048)
• SHIP
• State Office on Aging
• Internet
• www.ssa.gov
• www.medicare.gov
• www.cms.hhs.gov

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Key Concepts

• SSA determines disability
• Eligible for Medicare if you receive cash
  benefits
• Receive all benefits
• Eligible for all health care choices

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Thanks for your attention!
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• Medicare Entitlement
• Because of a Disability
• Detailed Information

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Supplemental Security Income (SSI)

• Based on financial need
• Must be 65 or over, or blind, or disabled
• Children may be eligible
• Benefits reduced for other income
• Call SSA at 1-800-772-1213 for more information

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Social Security Benefits(RSDI)

• Based on covered earnings
• Worker and certain family members may qualify
• See Social Security Statement for estimates
• Only certain types of income affect benefits

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Social Security Benefits(RSDI)

• Retirement benefits for yourself and your
• Husband or wife
• Dependent children
• Survivors benefits for your
• Widow or widower
• Dependent children
• Parents
• Disability benefits for yourself and your
• Husband or wife
• Dependent children

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Applying for Disability Benefits

• Apply as soon as you become disabled
• 1-year limit on retroactive benefits
• Call 1-800-772-1213 or visit any SSA office
• TTY number 1-800-325-0778
• Decision generally takes 60 to 90 days

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Disability Determination Service

• State agency
• Determines disability under Social Security law
• Considers
• Medical evidence
• Medical report forms
• Other information as necessary

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Consultative Examination

• When the DDS needs more medical information to
  decide your case
• Your doctor or medical facility is preferred
• Social Security pays for the exam and travel
  expenses
• May not be a complete examination

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Process for Determining Disability

• Step-by-step process involving 5 questions
• Are you working?
• Is your condition severe?
• Is your condition on list of disabling
  impairments?
• Can you do your previous work?
• Can you do any other type of work?

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Disability Decision

• Sent in a letter
• If approved, letter shows
• Benefit amount
• Date payments start
• If disapproved, letter explains
• Reason for denial
• How to appeal

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If Claim Is Approved

• Social Security benefits will be paid
• After 5 full months
• Amount of benefit based on lifetime average
  earnings
• Other payments may reduce benefit amount, e.g.,
  Workers Compensation
• Cash benefits may be taxed

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If Claim Is Denied

• May appeal any part of decision
• Must appeal within 60 days
• Social Security provides assistance

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Status of Cash Benefits

• Case is reviewed periodically
• Frequency depends on expectation of recovery
• Benefits continue based on disability status
• Cash benefits may stop if
• Earn 810 or more a month
• Medical condition improves and no longer disabled

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Termination from Medicare

• Entitlement to Part A ends
• Month of death
• Under 65 and no longer disabled
• Nonpayment of Part A premiums
• Voluntary termination (if buying Part A)
• Working, after 8½ years of premium-free Part A
• Entitlement to Part B ends
• Month of death
• Month Part A entitlement ends if under age 65
• Nonpayment of Part B premiums
• Voluntary termination

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Ticket to Work Provisions

1. Medicare coverage for some disabled working
   beneficiaries
2. Suspension of Medigap for EGHP
3. State Medicaid options on paying premiums for
   workers with disabilities

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(1) Extending Medicare Disability Benefits

• Disabled beneficiaries who return to work and
  whose earnings are considered substantial (810
  per month in 2004) can receive 8½ years of
  premium-free Medicare Part A

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(2) Suspending Medigap When Covered by Group Plan

• Beneficiaries entitled to Medicare because of
  disability can suspend Medigap while covered
  under an EGHP
• Can reinstate Medigap by giving notice of loss of
  coverage within 90 days

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(3) Expanding State Medicaid Options

• Working individuals with disabilities have
  increased opportunities to maintain Medicaid
  coverage