26 Nov Will Medicare or my employer plan cover my treatment costs?

Q. I recently started hemodialysis at age 61. I was told that I’m eligible for Medicare 90 days after I started treatment despite not yet being 65. Is that correct? I’m still working. Can I keep my employer group plan as a secondary to Medicare?
— Trying to get better

A. We wish you well with your treatment.

While Medicare coverage typically begins when an individual turns 65, there are exceptions for those with disabilities and folks like yourself, who have End-Stage Renal Disease (ESRD) that requires either dialysis or a transplant.

The information you were given about the waiting period is correct in principle, said Claudia Mott, a certified financial planner with Epona Financial Solutions in Basking Ridge.

She said Medicare coverage for someone with ESRD and who is on dialysis begins on the first day of the fourth month of treatment. Depending on the time of year, this could be 90 days or slightly longer, Mott said.

However, she said, there is a scenario when Medicare care coverage will begin the first month of dialysis: If the individual participates in a home dialysis training program offered by a Medicare-certified training center during the first three months of regular treatment and then self-administers their own treatments, coverage can begin in the first month.

“Please bear in mind that your Medicare coverage will end 12 months after the month you stop dialysis treatments if you are under age 65,” she said. “Coverage will resume if you start dialysis again or receive a transplant within a year of the month you stopped dialysis.”

Because of the waiting period associated with receiving your first dialysis treatment, your employer insurance will be the payer for those first three months, Mott said. In the event the employer-plan doesn’t cover all of your costs, you may be responsible for some of them, so speak with your employee benefit department to understand what the plan covers.

“Once Medicare coverage begins following the three-month waiting period, there is a `coordination period’ during which time your employer-plan will continue to cover your medical bills,” she said. “If your insurance doesn’t cover 100% of the costs, Medicare may pay some of them.”

This is called a “coordination of benefits” in which Medicare will be the secondary source of insurance for the next 30 months. If you participate in the home dialysis training, the coordination period will begin more quickly, she said.

“It is important that you inform your employer about your Medicare coverage in order to ensure proper billing,” she said. “Once the 30 month period elapses, Medicare will become the first payer for all Medicare-covered services.”

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This story was originally published on Nov. 26, 2021.

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