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Eligibility Requirements for Medicare document sample
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2004 REACH National Medicare Training Program
1
Medicare Entitlement Because of
ESRD or Disability
Module 6
2
Medicare for People with
End-Stage Renal Disease
Module 6
Lesson A
3
Session Topics
• Overview
• Eligibility and enrollment
• Coverage
• Health plan options
• Information sources
4
Session Topics
• Overview
• Eligibility and enrollment
• Coverage
• Health plan options
• Information sources
5
Overview
End-Stage Renal Disease
• Often referred to as ESRD
• Kidney impairment
– Appears irreversible and permanent
– Requires regular dialysis or a kidney transplant
to maintain life
6
Overview
Medicare for People with ESRD
• 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
7
Session Topics
Overview
• Eligibility and enrollment
• Coverage
• Health plan options
• Information sources
8
Eligibility and Enrollment
Part A Eligibility Requirements
• 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
9
Eligibility and Enrollment
Part B Eligibility
• 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
10
Eligibility and Enrollment
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
11
Eligibility and Enrollment
30-Month Coordination Period
• 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
12
Eligibility and Enrollment
Enrollment Decision
• 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
13
Eligibility and Enrollment
ESRD Coverage Begins
• 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
14
Eligibility and Enrollment
Coverage Ends
• 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
15
Eligibility and Enrollment
Coverage Continues or Resumes
• If dialysis is resumed
OR
• Another transplant is received
16
Let’s 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?
17
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?
18
Session Topics
Overview
Eligibility and enrollment
• Coverage
– Dialysis patients
– Transplant patients
• Health plan options
• Information sources
19
Coverage
Benefits
• 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
20
Coverage for Dialysis Patients
Covered Services
• Inpatient dialysis treatments
• Home dialysis training
• Self-dialysis training
• Home dialysis equipment and supplies
• Certain home support services
• Certain drugs for home dialysis
21
Coverage for Dialysis Patients
Ambulance Services
• 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
22
Coverage for Dialysis Patients
Home Dialysis
• 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
23
Coverage for Dialysis Patients
Services NOT Covered
• Paid dialysis aides
• Lost pay
• Place to stay during your treatment
• Blood for home dialysis
– Unless part of doctor’s service or needed to
prime the dialysis equipment
• Transportation to the dialysis facility
– Except in special cases
24
Coverage for Transplant Patients
Medicare Part A
• 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
25
Coverage for Transplant Patients
Medicare Part B for Kidney
Transplant
• Surgeon’s services
• Doctor’s 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
26
Coverage for Transplant Patients
Coverage for Blood
• 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
27
Coverage for Transplant Patients
Immunosuppressive Drugs
• 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
28
Coverage for Transplant Patients
Immunosuppressive Drugs
• 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
29
Let’s see what we know…
Which service is covered by
Medicare?
A. Paid dialysis aides
B. Lost pay
C. Kidney Registry fee
30
Let’s 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?
31
Session Topics
Overview
Eligibility and enrollment
Coverage
• Health plan options
• Information sources
32
Health Plan Options
Original Medicare
• Usually the only choice
• Always an option
33
Health Plan Options
Medicare Advantage Plans
• 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”
34
Health Plan Options
If Your Plan Leaves Medicare
• 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
35
Let’s 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?
36
Let’s 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.
37
Session Topics
Overview
Eligibility and enrollment
Coverage
Health plan options
• Information sources
38
Information Sources
ESRD Networks
• Ensure administration of ESRD benefits
• Develop quality standards
• Assess treatment modalities
• Provide technical assistance to dialysis facilities
• Educate beneficiaries
• Contact information: Local phone number
39
Information Sources
ESRD 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
40
Information Sources
www.medicare.gov
• Dialysis Facility Compare
– Searchable database
– Facility location
– Treatment choices offered
– Ownership
– Availability of evening services
– Quality measures
41
Information Sources
www.medicare.gov
• 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
42
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
43
Medicare Entitlement
Because of a Disability
Module 6
Lesson B
44
Session Topics
• Overview
• Eligibility and enrollment
• Health plan choices
• Information sources
45
Session Topics
• Overview
• Eligibility and enrollment
• Health plan choices
• Information sources
46
Overview
Coverage for Disabled
Beneficiaries
• Coverage began in 1973
• 1.7 million beneficiaries initially
• 5.6 million in 2001
– 14% of all Medicare beneficiaries
47
Overview
Medicare Enrollment Trend
48
Overview
Social Security and Medicare
• 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
49
Overview
Disability Defined
• 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
50
Session Topics
Overview
• Eligibility and enrollment
• Enrollment process
• Health plan choices
• Information sources
51
Eligibility and Enrollment
SSA Programs
• RSDI
– Based on covered earnings
– Funded by FICA
• SSI
– Based on need
– Funded by general revenues
• Both pay benefits for people with disabilities
52
Eligibility and Enrollment
Qualifying for Medicare
• 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
53
Eligibility and Enrollment
Qualifying for Disability Benefits
• Meet requirements for SSA disability
benefits
• 5-month waiting period before cash benefits
begin
54
Eligibility and Enrollment
Applying for Disability Benefits
• 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
55
Eligibility and Enrollment
Enrollment in Medicare
• Automatic enrollment in Original Medicare
– After 24 months of disability payments
• Except for ALS
– Will receive card by mail
• Call SSA if it doesn’t arrive
– Decide on Part B
56
Eligibility and Enrollment
Continuing Medicare Entitlement
• 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
57
Let’s 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?
58
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?
59
Session Topics
Overview
Eligibility and enrollment
• Health plan choices
• Information sources
60
Health Plan Choices
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
61
Health Plan Choices
Coverage
• Coverage same as for people 65 and over
• All Medicare covered benefits
• No special limitations
62
Session Topics
Overview
Eligibility and enrollment
Health plan choices
• Information sources
63
Information Sources
If You Want to Know More…
• 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
64
Key Concepts
• SSA determines disability
• Eligible for Medicare if you receive cash
benefits
• Receive all benefits
• Eligible for all health care choices
65
Thanks for your attention!
66
Medicare Entitlement
Because of a Disability
Detailed Information
67
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
68
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
69
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
70
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
71
Disability Determination Service
• State agency
• Determines disability under Social Security
law
• Considers
– Medical evidence
– Medical report forms
– Other information as necessary
72
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
73
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?
74
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
75
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., Worker’s Compensation
• Cash benefits may be taxed
76
If Claim Is Denied
• May appeal any part of decision
• Must appeal within 60 days
• Social Security provides assistance
77
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
78
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
79
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
80
(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
81
(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
82
(3) Expanding State Medicaid
Options
• Working individuals with disabilities have
increased opportunities to maintain
Medicaid coverage
83
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