2004 REACH National Medicare Training Program
Medicare Entitlement Because of ESRD or Disability Module 6
Medicare for People with End-Stage Renal Disease Module 6 Lesson A
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>...
End-Stage Renal Disease <ul><li>Often referred to as ESRD </li></ul><ul><li>Kidney impairment </li></ul><ul><ul><li>Appear...
Medicare for People with ESRD <ul><li>Coverage began in 1973 </li></ul><ul><li>Over 1 million received life-saving therapy...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment   </li></ul><ul><li>Coverage </li></ul><ul><l...
Part A Eligibility Requirements <ul><li>Eligible for Medicare Part A at any age if </li></ul><ul><ul><li>Regular dialysis ...
Part B Eligibility <ul><li>If entitled to Medicare Part A </li></ul><ul><ul><li>Can enroll in Part B </li></ul></ul><ul><u...
Enrollment <ul><li>Enroll at local SSA office </li></ul><ul><li>May delay enrollment if covered by GHP </li></ul><ul><li>G...
30-Month Coordination Period <ul><li>During coordination period </li></ul><ul><ul><li>GHP pays first </li></ul></ul><ul><u...
Enrollment Decision <ul><li>Can delay enrollment in Medicare (Part A and Part B)  </li></ul><ul><li>Considerations in dela...
ESRD Coverage Begins <ul><li>Third month after the month dialysis begins </li></ul><ul><li>First month if certain conditio...
Coverage Ends <ul><li>If ESRD is the ONLY reason you were entitled </li></ul><ul><li>12 months after month you no longer r...
Coverage Continues or Resumes <ul><li>If dialysis is resumed  </li></ul><ul><ul><li>OR  </li></ul></ul><ul><li>Another tra...
Let’s see what we know… <ul><li>Your 30-month coordination period begins when your eligibility or entitlement begins, even...
Here is a case study… <ul><li>Brad is 59 and is entitled to Medicare based on ESRD. He began dialysis 3 months ago, so he ...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><ul>...
Benefits <ul><li>All services covered by Original Medicare </li></ul><ul><ul><li>Medicare Part A </li></ul></ul><ul><ul><l...
Covered Services <ul><li>Inpatient dialysis treatments </li></ul><ul><li>Home dialysis training </li></ul><ul><li>Self-dia...
Ambulance Services <ul><li>Transportation to dialysis facility </li></ul><ul><ul><li>Covered only if other forms of transp...
Home Dialysis <ul><li>Types of dialysis that can be performed at home </li></ul><ul><ul><li>Hemodialysis </li></ul></ul><u...
Services NOT Covered <ul><li>Paid dialysis aides </li></ul><ul><li>Lost pay </li></ul><ul><li>Place to stay during your tr...
Medicare Part A <ul><li>Covers inpatient hospital services for kidney transplant </li></ul><ul><ul><li>Transplant </li></u...
Medicare Part B for Kidney Transplant <ul><li>Surgeon’s services </li></ul><ul><li>Doctor’s services to donor </li></ul><u...
Coverage for Blood <ul><li>Part A and Part B can help pay for </li></ul><ul><ul><li>Whole blood </li></ul></ul><ul><ul><li...
Immunosuppressive Drugs <ul><li>Used to reduce the risk of rejection </li></ul><ul><li>Taken for the rest of your life  </...
Immunosuppressive Drugs <ul><li>If you have Medicare only because of ESRD, Medicare will pay for immunosuppressive drug th...
Let’s see what we know… <ul><li>Which service is covered by Medicare? </li></ul><ul><ul><li>Paid dialysis aides </li></ul>...
Let’s look at a case study… <ul><li>Jeff is 48 years old and just applied for Medicare based on ESRD. He knows that he wil...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>...
Original Medicare <ul><li>Usually the only choice </li></ul><ul><li>Always an option </li></ul>Health   Plan   Options
Medicare Advantage Plans <ul><li>Usually not an option for those with ESRD </li></ul><ul><li>May stay in a plan if already...
If Your Plan Leaves Medicare <ul><li>You have options </li></ul><ul><ul><li>Can return to the Original Medicare Plan </li>...
<ul><li>People with Medicare who are entitled because of ESRD can receive both Part A and Part B services. </li></ul><ul><...
Let’s look at a case study… <ul><li>Rachel is 43 years old and was diagnosed with ESRD 8 months ago. She has looked at som...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>...
ESRD Networks <ul><li>Ensure administration of ESRD benefits </li></ul><ul><li>Develop quality standards </li></ul><ul><li...
ESRD Information Sources <ul><li>American Association of Kidney Patients </li></ul><ul><ul><li>1-800-749-2257  </li></ul><...
www.medicare.gov <ul><li>Dialysis Facility Compare </li></ul><ul><ul><li>Searchable database </li></ul></ul><ul><ul><li>Fa...
www.medicare.gov <ul><li>Quality measures for dialysis facilities </li></ul><ul><ul><li>How well facility treats patients ...
Key Concepts <ul><li>Most people with ESRD are eligible for Medicare </li></ul><ul><li>It is important to understand enrol...
Medicare Entitlement Because of a Disability Module 6 Lesson B
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Health plan choices </li></...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Health plan choices </li></...
Coverage for Disabled Beneficiaries <ul><li>Coverage began in 1973 </li></ul><ul><li>1.7 million beneficiaries initially <...
Medicare Enrollment Trend Overview
Social Security and Medicare <ul><li>Relationship between Social Security and Medicare </li></ul><ul><ul><li>Medicare is t...
Disability Defined <ul><li>Social Security definition </li></ul><ul><ul><li>Inability to work </li></ul></ul><ul><ul><li>W...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Enrollment process </li></u...
SSA Programs <ul><li>RSDI </li></ul><ul><ul><li>Based on covered earnings </li></ul></ul><ul><ul><li>Funded by FICA </li><...
Qualifying for Medicare <ul><li>Usually begins after 24 months of benefits </li></ul><ul><li>Exceptions </li></ul><ul><ul>...
Qualifying for Disability Benefits <ul><li>Meet requirements for SSA disability benefits </li></ul><ul><li>5-month waiting...
Applying for Disability Benefits <ul><li>Take your </li></ul><ul><ul><li>Social Security Number </li></ul></ul><ul><ul><li...
Enrollment in Medicare <ul><li>Automatic enrollment in Original Medicare </li></ul><ul><ul><li>After 24 months of disabili...
Continuing Medicare Entitlement <ul><li>Ends when SSA determines you are no longer disabled </li></ul><ul><li>Continues fo...
Let’s see what we have learned... <ul><li>Most people who are receiving cash benefits for a disability are eligible for Me...
Here is a case study… <ul><li>Ramon has been told that he meets the Social Security definition for blindness.  He knows he...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Health plan choices </li></...
Choices <ul><li>All Medicare plans available </li></ul><ul><ul><li>Original Medicare Plan </li></ul></ul><ul><ul><li>Medic...
Coverage <ul><li>Coverage same as for people 65 and over </li></ul><ul><li>All Medicare covered benefits </li></ul><ul><li...
Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Health plan choices </li></...
If You Want to Know More… <ul><li>SSA 1-800-772-1213 (TTY 1-800-325-0778) </li></ul><ul><li>1-800-MEDICARE (TTY 1-877-486-...
Key Concepts <ul><li>SSA determines disability </li></ul><ul><li>Eligible for Medicare if you receive cash benefits </li><...
Thanks for your attention!
<ul><li>Medicare Entitlement </li></ul><ul><li>Because of a Disability </li></ul><ul><li>Detailed Information </li></ul>
Supplemental Security Income (SSI) <ul><li>Based on financial need  </li></ul><ul><li>Must be 65 or over, or blind, or dis...
Social Security Benefits (RSDI) <ul><li>Based on covered earnings </li></ul><ul><li>Worker and certain family members may ...
Social Security Benefits (RSDI) <ul><li>Retirement benefits for yourself and your </li></ul><ul><ul><li>Husband or wife </...
Applying for Disability Benefits <ul><li>Apply as soon as you become disabled </li></ul><ul><ul><li>1-year limit on retroa...
Disability Determination Service <ul><li>State agency </li></ul><ul><li>Determines disability under Social Security law </...
Consultative Examination <ul><li>When the DDS needs more medical information to decide your case </li></ul><ul><li>Your do...
Process for Determining Disability <ul><li>Step-by-step process involving 5 questions </li></ul><ul><ul><li>Are you workin...
Disability Decision <ul><li>Sent in a letter </li></ul><ul><li>If approved, letter shows </li></ul><ul><ul><li>Benefit amo...
If Claim Is Approved <ul><li>Social Security benefits will be paid </li></ul><ul><ul><li>After 5 full months  </li></ul></...
If Claim Is Denied <ul><li>May appeal any part of decision </li></ul><ul><li>Must appeal within 60 days </li></ul><ul><li>...
Status of Cash Benefits <ul><li>Case is reviewed periodically </li></ul><ul><ul><li>Frequency depends on expectation of re...
Termination from Medicare <ul><li>Entitlement to Part A ends </li></ul><ul><ul><li>Month of death </li></ul></ul><ul><ul><...
Ticket to Work Provisions <ul><li>Medicare coverage for some disabled working beneficiaries </li></ul><ul><li>Suspension o...
(1) Extending Medicare  Disability Benefits  <ul><li>Disabled beneficiaries who return to work and whose earnings are cons...
(2) Suspending Medigap When Covered by Group Plan <ul><li>Beneficiaries entitled to Medicare because of disability can sus...
(3) Expanding State Medicaid Options <ul><li>Working individuals with disabilities have increased opportunities to maintai...
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2004 REACH National Medicare Training Program

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  • This training module was developed and approved by the Centers for Medicare &amp; Medicaid Services (CMS), the federal agency that administers Medicare and Medicaid. This agency was formerly known as the Health Care Financing Administration (HCFA). Throughout these materials, you may see references to HCFA publications; these were created by the agency under its former name and retain the name temporarily. The information in this module was correct at the time of printing (June 2004). This set of National Medicare Training Program materials is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.
  • This module gives information about those who are entitled to Medicare because of End-Stage Renal Disease (ESRD) or a disability. It is divided into two lessons, one for ESRD and one for disability. References: Medicare Coverage of Kidney Dialysis and Kidney Transplant Services, CMS Publication 10128, December 2003 HCFA Legislative Summary , January 2000 SSA, Office of Disability Publication No. 64-040 (Special Edition 2000)
  • Lesson A of Module 6, Medicare Coverage for People with End-Stage Renal Disease , addresses the special benefits and guidelines for those entitled to Medicare because they have End-Stage Renal Disease. End-Stage Renal Disease is commonly referred to as ESRD.
  • In this lesson we will: Review the program Learn the eligibility requirements for people with ESRD Describe their coverage Define health plan options and coverage Identify further sources of information
  • Let’s start with an overview of Medicare for people entitled because of End-Stage Renal Disease.
  • End-Stage Renal Disease (ESRD) is defined as that stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or a kidney transplant to maintain life.
  • In 1972, Medicare was expanded to include Americans living with disabilities and those with ESRD. Coverage began in 1973. Since 1973, more than 1 million Americans have received life-saving renal replacement therapy, either dialysis or transplantation. Statistics show that over 350,000 people are alive on renal replacement therapy, and 90,000 persons have had a successful kidney transplant, including some 20,000 whose medical condition improved so much that they left the Medicare program.
  • Now let’s talk about eligibility and enrollment for these individuals.
  • You can get Medicare Part A no matter how old you are if your kidneys no longer function and you need regular dialysis or a kidney transplant, and: You have worked the required amount of time under Social Security, for a railroad, or as a government employee; OR You are getting or are eligible for Social Security or Railroad Retirement benefits; OR You are the spouse or dependent child of a person who has worked the required amount of time under Social Security, for a railroad, or as a government employee.
  • If you get Medicare Part A, you can also get Medicare Part B. Enrolling in Part B is your choice. You will need both Part A and Part B in order for Medicare to cover certain dialysis and kidney transplant services. If you can’t get Medicare, you may be able to get help from your state to pay for your dialysis treatments. Call the Social Security Administration at 1-800-772-1213 for more information about the amount of work needed under Social Security to be eligible for Medicare. If you have railroad employment, call the Railroad Retirement Board (RRB) at 1-800-808-0772 or your local RRB office.
  • You can enroll in Medicare Part A and Part B based on ESRD at your local Social Security office. Call your local Social Security office to make an appointment to enroll in Medicare based on ESRD. You may delay applying for Medicare if you are covered by a group health plan (GHP). It is important to understand the provisions of enrollment and eligibility, especially if you will soon receive an organ transplant. We will talk about the transplant issue on a later slide. In general, Medicare is the secondary payer of benefits for the first 30 months of Medicare eligibility for those with ESRD who have group health plan coverage. If you have Part A because of age or disability, but did not take Part B or your Part B coverage was stopped, you can enroll in Part B without paying a higher premium rate if you enroll in Medicare based on ESRD. If you already have Part B and are paying a late enrollment surcharge, this will eliminate the surcharge.
  • If you are eligible for Medicare because of permanent kidney failure, your Medicare coverage will usually start the fourth month of dialysis. Medicare will not pay anything during your first 3 months of dialysis unless you already have Medicare because of age or disability. Therefore, your group health plan (GHP) is the only payer for the first 3 months of dialysis. When you are eligible for Medicare because of kidney failure, there is a period of time when your group health plan will pay first on your health care bills and Medicare will pay second. This period of time is called a 30-month coordination period . Medicare is called the secondary payer during this coordination period. The 30-month coordination period starts the first month you are able to get Medicare, even if you have not signed up yet. For example, if you start dialysis in June, the 30-month coordination period will start September 1, the fourth month of dialysis. If you have employer group health plan coverage during the 30-month coordination period, it is very important that you tell the person who provides your medical care so your services are billed correctly. After the 30-month coordination period, Medicare will pay first for all Medicare-covered services. Your employer GHP plan coverage may pay for services not covered by Medicare. Check with your plan’s benefits administrator. There is a separate 30-month coordination period each time you enroll in Medicare based on kidney failure. For example, if you get a kidney transplant that continues to work for 36 months, your Medicare coverage will end. If after 36 months you enroll in Medicare again because you start dialysis or get another transplant, your Medicare coverage will start right away. There will be no 3-month waiting period before Medicare begins to pay. There will be a new 30-month coordination period if you have employer GHP coverage.
  • You do not have to enroll in Medicare Part A and Part B. You should think carefully about this decision. If you already have a group health plan, consider the following: If you must pay a yearly deductible or coinsurance under your group health plan, enrolling in Medicare Parts A and B could pay those costs. If your group health plan coverage does not have a yearly deductible or coinsurance and will pay all of your health care costs, you may want to delay enrolling in Medicare until the 30-month coordination period is over. If you enroll in Medicare Part A and do not enroll in Part B, you will not be paying the Part B premium. However, you will be able to enroll only during a General Enrollment Period; you will not have a Special Enrollment Period and your Part B premium may be higher. If you delay enrollment in Part A and Part B, you will not be paying the Part B premium, but you will get Part B the same time you get Part A. One important consideration is that immunosuppressive drug therapy is only covered by Medicare for people who have received transplants if they were entitled to Part A when the transplant was performed at a Medicare approved facility and Medicare made payment for transplant, OR if Medicare made no payment, Medicare was secondary payer, AND he or she is enrolled in Part B at the time of the immunosuppressive drug therapy. This benefit is now available for as long as a person is covered by Medicare . That means that if you delay enrolling in Medicare and have a transplant under your group health plan, your immunosuppressive drugs will not be covered by Medicare.
  • Coverage for people with ESRD begins at different times depending on the circumstances. When you first enroll in Medicare based on ESRD (permanent kidney failure) and you are on dialysis, your Medicare coverage usually starts the fourth month of dialysis treatments. For example, if you start getting your hemodialysis treatments in July, your Medicare coverage would start on October 1. If you are covered by an employer group health plan, your Medicare coverage will still start the fourth month of dialysis treatments. Your employer group health plan will pay first on your health care bills and Medicare will pay second for a 30-month coordination period . Coverage will begin the first month of dialysis treatments if you participate in a self-dialysis training program in a Medicare-approved training facility before the third month after dialysis begins and you expect to complete training and self-dialyze after that. Coverage also begins the first month of dialysis treatments if you were previously entitled to Medicare due to ESRD. Medicare coverage begins the month you receive a kidney transplant or the month you are admitted to an approved hospital for transplant or for procedures preliminary to transplant, providing that the transplant takes place in that month or within the 2 following months. Medicare coverage can start 2 months before the month of your transplant if your transplant is delayed more than 2 months after you are admitted to the hospital for the transplant or for health care services you need before your transplant.
  • We’ve discussed how coverage begins. There are other circumstances in which coverage might end or need to be continued or resumed. Coverage ends if ESRD is the ONLY reason you are covered by Medicare (i.e., you are not 65 or otherwise disabled) AND you do not require maintenance dialysis for 12 months OR 36 months have passed after the month of a kidney transplant.
  • Coverage will continue if you resume dialysis within 12 months after you stopped getting dialysis, or start dialysis or receive another kidney transplant before the 36-month post-transplant period ends. Coverage will resume with no waiting period if you start dialysis more than 12 months after the previous course of dialysis ended or more than 36 months after the month of a kidney transplant. It is important to note that in this situation, the individual must file a new application for Medicare.
  • True! This is correct.
  • Yes, he is correct. Coverage for people with ESRD begins at different times depending on the circumstances. When you first enroll in Medicare based on ESRD (permanent kidney failure) and you are on dialysis, your Medicare coverage usually starts the fourth month of dialysis treatments. For example, if you start getting your hemodialysis treatments in July, your Medicare coverage would start on October 1. However, coverage will begin the first month of dialysis treatments begin if you participate in a self-dialysis training program in a Medicare-approved training facility and you expect to complete training and self-dialyze after that. Coverage also begins the first month of dialysis treatments if you were previously entitled to Medicare due to ESRD. Medicare coverage begins the month you receive a kidney transplant or the month you are admitted to an approved hospital for transplant or for procedures preliminary to transplant, providing that the transplant takes place in that month or within the following 2 months. Medicare coverage can start 2 months before the month of your transplant if your transplant is delayed more than 2 months after you are admitted to the hospital for the transplant or for health care services you need before your transplant. (Note to instructor: the scenario on this slide is meant to generate discussion. Use if appropriate and time permits .)
  • Now let’s talk about what is covered for these individuals.
  • Let’s discuss the services that are covered for people with ESRD. As a person entitled to Medicare based on ESRD, you are entitled to all Medicare Part A and Medicare Part B services covered by the Original Medicare Plan. Special services are available for those with ESRD. These services cover immunosuppressive drugs for transplant patients (certain conditions must be met) and other services for dialysis patients.
  • Let’s look at the special covered services for dialysis patients. Dialysis is a treatment that cleans your blood when your kidneys don’t work. It gets rid of harmful wastes and extra salt and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids. Dialysis treatments help you feel better and live longer, but they are not a cure for permanent kidney failure. Covered treatments and services include: Inpatient dialysis treatments Facility dialysis treatments Home dialysis training Self-dialysis training Home dialysis equipment and supplies Certain home support services Certain drugs for home dialysis
  • Does Medicare pay for transportation to dialysis facilities? In most cases, no. Medicare covers round-trip ambulance services from home to the nearest dialysis facility only if other forms of transportation would be harmful to your health. The ambulance supplier must get a written order from your main doctor before you get the ambulance service. The doctor’s written order must be dated no earlier than 60 days before you get the ambulance service. For more information about ambulance coverage, call 1 800 MEDICARE (1-800-633-4227); TTY/TDD 1-877-486-2048 , your Part B carrier, or your State Health Insurance Assistance Program (SHIP).
  • There are two types of dialysis that can be performed at home, hemodialysis and peritoneal dialysis. Hemodialysis uses a special filter (called a dialyzer) to clean your blood. The filter connects to a machine. During treatment, your blood flows through tubes into the filter to clean out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into your body. Peritoneal dialysis uses a cleaning solution, called dialysate, that flows through a special tube into your abdomen. After a few hours, the dialysate gets drained from your abdomen, taking the wastes from your blood with it. Then you fill your abdomen with fresh dialysate and the cleaning process begins again. Medicare Part B covers some drugs for home dialysis, including: heparin the antidote for heparin when medically necessary topical anesthetics Epogen® or Epoetin alfa.
  • It’s also important to understand what Medicare does not pay for. Below are services and supplies that are not covered: Paid dialysis aides to help with home dialysis Any lost pay to you and the person who may be helping you during self- dialysis training A place to stay during your treatment Blood or packed red blood cells for home dialysis unless part of a doctors’ service or is needed to prime the dialysis equipment Transportation to the dialysis facility except in special cases (ambulance services, discussed earlier)
  • Although Medicare covers medically necessary hospitalization for ESRD patients, those who are undergoing a kidney transplant have special coverage. Medicare Part A covers inpatient hospital services for a kidney transplant and/or preparation for a transplant. It also covers the Kidney Registry fee and laboratory tests. The full cost of care for the kidney donor in the hospital is covered, including any care necessary due to complications.
  • Medicare Part B covers surgeon’s services for a transplant for both the patient and the donor. (Medicare covers both living and cadaver donors.) There is no deductible to be met for the donor. Medicare Part B also covers immunosuppressive drug therapy necessary following a kidney transplant if the person was entitled to Part A at time of transplant and Medicare made payment for transplant OR if Medicare made no payment but was the secondary payer for a transplant performed in a Medicare kidney transplant approved facility. This type of drug therapy is necessary to lessen the risk that the transplanted kidney will be rejected.
  • Both Medicare Part A and Medicare Part B can help pay for whole blood or units of packed red blood cells, blood components, and the cost of blood processing and administration after the Medicare Part A and/or Part B deductible are met. If you paid for or replaced some units of blood under Medicare Part B (or Medicare Part A) during the calendar year, you don’t have to do so again under Medicare Part A (or Medicare Part B). Details about coverage for blood are available from the Centers for Medicare &amp; Medicaid Services’ publications or through the End-Stage Renal Disease Network (ESRD Network).
  • Immunosuppressive drugs are drugs used to reduce the risk of your body rejecting your new kidney after your transplant. You will probably need to take these drugs for the rest of your life. If you stop taking them, your body may reject your new kidney and the kidney could stop working. If that happens, you will have to start dialysis again. If you already had Medicare because of age or disability before you got ESRD, or if you became eligible for Medicare because of age or disability after receiving a transplant that was paid for by Medicare, or paid for by private insurance that paid primary to your Medicare Part A coverage, in a Medicare-certified facility, Medicare will continue to pay for your immunosuppressive drugs with no time limit. You must have Medicare Part B at the time of the dispensing of the drug. If you have Medicare only because of kidney failure, your Medicare will end 36 months after the month of the transplant.
  • As we discussed earlier, in order for Medicare to pay for your immunosuppressive drug therapy, you must have been entitled to Medicare Part A at the time of the transplant and Medicare made payment for transplant, OR if Medicare made no payment, Medicare was secondary payer. You also must be enrolled in Medicare Part B at the time of the immunosuppressive drug therapy.
  • C. Kidney Registry fee.
  • Yes, Jeff is correct. In order for Medicare to pay for his immunosuppressive drug therapy, he must be entitled to Medicare Part A at the time his transplant is performed in a Medicare-approved facility, and Medicare must pay for transplant OR, if Medicare makes no payment, Medicare is secondary payer. He also must be enrolled in Medicare Part B at the time of the immunosuppressive drug therapy. His immunosuppressive drug therapy will be covered by Medicare because he will be enrolled in Medicare Part B at the time of the drug therapy. If he has Medicare only because of kidney failure, his immunosuppressive drug therapy coverage will end 36 months after the month of the transplant. If a person already had Medicare because of age or disability before getting ESRD, or became eligible for Medicare because of age or disability after receiving a transplant, in a Medicare-certified facility, that was paid for by Medicare (or paid for by private insurance that was primary to Medicare Part A coverage), Medicare will continue to pay for immunosuppressive drugs with no time limit. Note to instructor: the scenario on this slide is meant to generate discussion. Use if time permits and if appropriate.
  • Now let’s talk about the health plan options available for people with ESRD. One of the plan options we’ll be talking about is Medicare Advantage (formerly known as Medicare + Choice plan). Medicare Advantage is the new name for Medicare + Choice plans beginning in 2004. Medicare Advantage rules and payments have been improved to give you more health plan choices and better benefits. Plan choices might have improved already in your area. If you are happy with the Medicare coverage you have, you can keep it exactly the same. Or you can choose to enroll in one of these new options. No matter what you decide, you are still in the Medicare program. The term Medicare Advantage plan (formerly Medicare + Choice) includes Medicare Managed Care plans and Private Fee-for-Service plans.
  • The Original Medicare Plan is usually the only choice if you are entitled to Medicare because of ESRD.
  • Medicare Advantage plans, such as Managed Care plans and Private Fee-for-Service plans are generally not available to you, although there are some people with ESRD who may stay in or join a Medicare Advantage plan. These rules are part of the legislation which created the Medicare Advantage plan choices. Let’s discuss the situations where a person entitled to Medicare because of ESRD might be able to stay in or join an Medicare Advantage plan. People who start dialysis and are already in a Medicare Managed Care plan or Private Fee-for-Service plan can stay in the plan they are in or join another plan offered by the same company in the same state. If you’ve had a successful kidney transplant, you may be able to join a plan. If you have ESRD and are in a plan that leaves Medicare or no longer provides coverage in your area, you can join another Medicare Managed Care plan or Private Fee-for-Service plan if one is available in your area. (This is true for people whose plans left Medicare or stopped providing coverage in their area on or after December 31, 1998.) You may also remain in a plan if you “age in.” This means that you were in a non-Medicare health plan, became eligible for Medicare on any basis (ESRD, disability, or age 65), and you join a plan offered by the same organization that offered the non-Medicare health plan you were in. If you leave an Medicare Advantage plan for other reasons after developing ESRD, you can choose only the Original Medicare Plan. However, the Original Medicare Plan is always an option.
  • If you have ESRD and are in a Medicare Managed Care plan or Private Fee-for-Service plan and the plan leaves Medicare or no longer provides coverage in your area, you can join another Medicare Managed Care plan or Private Fee-for-Service plan if one is available in your area, providing the plan you want to join is not at capacity and is accepting new members. This is true for people whose plans left Medicare or stopped providing coverage in their area on or after December 31, 1998.
  • True!
  • No, she cannot join the managed care plan. Medicare Advantage plans, such as managed care plans and Private Fee-for-Service plans are generally not available to people entitled because of ESRD The following are situations where a person entitled to Medicare because of ESRD might be able to stay in or join a Medicare Advantage plan. People who start dialysis and are already in a Medicare Managed Care plan or Private Fee-for-Service plan can stay in the plan they are in or join another plan offered by the same company in the same state. If you’ve had a successful kidney transplant, you may be able to join a plan. If you have ESRD and are in a plan and the plan leaves Medicare or no longer provides coverage in your area, you can join another Medicare managed care plan or Private Fee-for-Service plan if one is available in your area. (This is true for people whose plans left Medicare or stopped providing coverage in their area on or after December 31, 1998.) You may also remain in a plan if you “age in.” This means that you were in a non-Medicare health plan, became eligible for Medicare on any basis (ESRD, disability, or age 65), and you join a plan offered by the same organization that offered the non-Medicare health plan you were in. (Note to instructor: the scenario on this slide is meant to generate discussion. Use if time permits and if appropriate .)
  • We now have a solid knowledge base of how the Medicare program works for people with ESRD. Our last topic is perhaps the most important—where to get more information.
  • The End-Stage Renal Disease networks are excellent sources of information. These organizations are responsible for developing criteria and standards related to the quality and appropriateness of care for patients who have ESRD. They also provide technical assistance to the dialysis facilities. Like other CMS agents and partners, they help educate beneficiaries about the Medicare program. You can get contact information for your local ESRD network in the back of Medicare Coverage of Kidney Dialysis and Kidney Transplant Services , CMS Publication 10128, December 2003.
  • Other sources of information for those with ESRD include: The American Association of Kidney Patients The National Kidney Foundation The American Kidney Fund Those who have ESRD have specific information needs. Be sure to read the available information carefully and ask questions when necessary.
  • You will be able to get important information about Medicare-certified dialysis facilities in your area on the Internet at www.medicare.gov. Click on “Dialysis Facility Compare.” This website includes information on the location of dialysis facilities in your state, the treatment choices they offer, ownership information, whether evening shifts are available, and information on some quality measures. We will talk about these quality measures on the next slide. If you don’t have access to the Internet or are not familiar with it, you might seek assistance from a family member or friend who is familiar with the Internet. And you can always go to the public library or senior center and use their computers at minimal or no charge.
  • Quality means how well a facility treats its patients. Good quality dialysis care means doing the right thing, at the right time, in the right way, for the right person, and getting the best possible results. You can find information on the website to help you understand why these measures are important. You should also discuss the quality measures information with the dialysis facility staff and/or your physician to help you understand what they mean and to find out what the most recent results are for the facility. Some measures of quality for dialysis facilities are: Percent of hemodialysis patients adequately dialyzed Percent of patients whose anemia is adequately managed Patient survival information
  • Let’s review some key concepts. We have learned that most people with ESRD are eligible for Medicare. We discussed their enrollment options and learned they receive all Part A and Part B services, as well as some additional services. We also learned the Original Medicare Plan is the only choice most people with ESRD have for health care coverage. And, we know there is much more information available.
  • Module 6, Lesson B, Medicare Entitlement Because of a Disability , addresses the special benefits and guidelines for this Medicare population.
  • This lesson will focus on people who are entitled to Medicare because of a disability. At the end of this section on Medicare and disabilities, you should understand: Eligibility requirements Enrollment process Health plan choices available to disabled beneficiaries Information sources You will also be provided with a list of resources to assist in obtaining additional information regarding Social Security disability programs and Medicare. Since the provisions for disabled beneficiaries can be complicated, it is important to know where to go for more information. The first part of this lesson provides basic information about Medicare for people with disabilities. The last part will provide more detail about the application and approval process and special Medicare provisions for these individuals.
  • Let’s first learn a few basic facts about Medicare eligibility because of a disability.
  • The Medicare program expanded to cover certain disabled persons in July 1973. According to 2003 CMS Statistics , CMS publication number 03445, in 2001 over 5½ million beneficiaries were enrolled because of disability, comprising 14 percent of the total Medicare population.
  • This graph shows the trend in Medicare enrollment. In fiscal year 1997, the population of Medicare beneficiaries consisted of 87 percent age 65 or over and about 13 percent disabled (including those with End-Stage Renal Disease). The disabled population is expected to grow to almost 16 percent of beneficiaries by 2017.
  • To understand Medicare entitlement based on disability, it helps to first understand the relationship between Social Security and Medicare. Medicare is title XVIII of the Social Security Act, and most people become eligible for Medicare because of their entitlement to Social Security benefits . (Qualified government employees, railroad employees, and others also are eligible for Medicare.) On July 30, 1965, President Lyndon Johnson signed the Social Security Act of 1965 to provide Medicare health insurance for the elderly (people 65 and over), as well as Medicaid coverage for the poor. The 1972 Social Security Amendments expanded Medicare to cover disabled persons under age 65 who have been entitled to Social Security benefits for 24 months and persons with End-Stage Renal Disease (ESRD) who meet special Social Security earnings requirements. (We covered Medicare entitlement based on ESRD in Lesson A of this module.) Medicare was administered by the Social Security Administration (SSA) until 1977, when it became the responsibility of the Centers for Medicare &amp; Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA). However, the laws that govern the Medicare program are still found in the Social Security Act.
  • SSA determines eligibility for disability benefits. To receive Social Security disability benefits, the law requires that you must have a physical and/or mental condition that keeps you from working and is expected to last at least a year or result in death. The impairment must keep you from doing any substantial work. If you are working in 2004 and your earnings average more than $810 a month , you generally cannot be considered disabled. You must not only be unable to do your previous work, but also any other type of work considering your age, education, and work experience. No benefits are payable for partial disability or for short-term disability. You may qualify as a disabled beneficiary if you are blind. SSA considers you to be legally blind under Social Security rules if your vision cannot be corrected to better than 20/200 in your better eye, or if your visual field is 20 degrees or less, even with a corrective lens (a condition known as “tunnel vision”). Many people who meet the legal definition of blindness still have some sight and may be able to read large print and get around without a cane or a guide dog. In 2004, people who are blind can earn up to $1,350 a month in 2004 before their work is considered substantial. There are two exceptions to these disability rules: No person is considered disabled if drug or alcohol abuse is a material contributing factor No cash benefit can be paid to someone whose disability is related to his or her commission of a felony
  • Now let’s talk about eligibility requirements.
  • SSA administers two major programs: Retirement, Survivors and Disability Insurance (RSDI), which is title II of the Social Security Act RSDI benefits are commonly known as Social Security benefits and are sometimes referred to as Old-Age, Survivors and Disability Insurance (OASDI) benefits Eligibility is based on a person’s lifetime history of earnings covered by Social Security This program is funded by Social Security (FICA) taxes. (FICA stands for &amp;quot;Federal Insurance Contributions Act.&amp;quot; It’s the tax withheld from your salary or self-employment income that funds the Social Security and Medicare programs.) Supplemental Security Income (SSI), which is title XVI of the Social Security Act Eligibility is based on need, and the program is funded by general tax revenues (not by Social Security taxes) Both of these programs pay cash benefits for people with disabilities.
  • As we said earlier, most people get Medicare because of their entitlement to Social Security, including Social Security disability benefits. In most cases, you must be entitled to disability benefits for 24 months before Medicare can begin, so the earliest you can receive Medicare is usually the 30th month after you become disabled. However, there are two exceptions: The 5-month waiting period for cash benefits does not apply to childhood disability beneficiaries or to some people who were previously entitled to disability benefits. The 24-month Medicare waiting period does not apply to people disabled by Amyotrophic Lateral Sclerosis (ALS, known as Lou Gehrig’s Disease). People with ALS get Medicare the first month they are entitled to disability benefits. This provision became effective on July 1, 2001. The requirements may be different for qualified government employees and railroad employees, who also may be eligible for Medicare based on a disability. Contact SSA or the Railroad Retirement Board for information about Medicare entitlement for these individuals.
  • Once you have filed an application, SSA will determine if you meet all of the requirements to receive cash benefits. In addition to meeting the definition of disability, you must qualify based on either (1) your own work credits or (2) your relationship to someone who has earned the required number of work credits. (People can earn up to a maximum of 4 work credits per year.) To qualify based on your own work, you must have worked long enough and recently enough under Social Security. The number of work credits you need depends on your age when you become disabled. Generally, you must have worked 5 years—earned 20 work credits—during the last 10 years that you were able to work. However, younger workers may qualify with fewer credits. A disabled widow or widower must be at least age 50 and meet certain other requirements to qualify. To receive childhood disability benefits, the child must be age 18 or over, unmarried (in most cases), and disabled since before age 22. In most cases, there is a waiting period of 5 full calendar months before benefits can begin. If your application is approved, your first Social Security benefit will be paid for the sixth full month after the date your disability began. (Note: There is no waiting period for SSI disability benefits.)
  • You can help shorten the process by taking certain documents with you when you apply and by helping SSA get the medical evidence to show that you are disabled. This includes: Social Security number and proof of age for each person applying, and dates of prior marriages if your spouse is applying Names, addresses, phone numbers, and dates of treatment for the doctors, hospitals, clinics, and institutions that have treated you Names of all medications you are taking If available, your medical records showing exams, treatments, and laboratory and other test results A summary of where you have worked and the kind of work you did, including your most recent W-2 form (Wage and Tax Statement), or if you are self-employed, your federal tax return IMPORTANT: You will need to provide original documents or copies certified by the issuing office. SSA will make photocopies and return your original documents. Don’t wait to file your claim for disability benefits, even if you don’t have all this information. The Social Security office will help you get the information you need.
  • You are automatically enrolled in the Original Medicare Plan when you have received at least 24 months of Social Security disability payments (or the first month you are entitled because of ALS). You should receive a Medicare card in the mail 3 months prior to your 25th month of disability benefits. If you do not receive your card, or if you have any questions about when you should be receiving your card, you should call 1-800-772-1213 or your local SSA office. Once you have received your Medicare card, you must decide if you want to keep Part B of Medicare. Some people may not need Part B. For example, they may have health care coverage under an employer group health plan based on current work by a spouse or a parent. Before you decide, check with SSA or CMS to be sure you won’t be charged a higher Part B premium for late enrollment if you later decide you do want Part B. Instructions are sent with the Medicare card explaining what to do if you do not want Part B. If you decide that you want Part B, you can choose to remain with the Original Medicare Plan or select another health plan option.
  • As long as you continue to meet the requirements for Social Security disability benefits, you continue to be entitled to Medicare. If SSA determines that your benefits should stop because of medical recovery (your medical condition has improved and no longer meets the disability definition), your Medicare entitlement based on disability ends. Social Security has work incentives to support people who are still medically disabled but try to work in spite of their disability. Continuation of Medicare coverage is one type of work incentive. You may have at least 8½ years of extended Medicare coverage if you return to work. Medicare continues even if SSA determines that you are no longer entitled to cash benefits because you are earning above the substantial gainful activity level ($810 per month in 2004). After this period, you may buy Medicare Part A (and Part B) for as long as you continue to be disabled. You will receive Medicare premium bills every 3 months. If you are receiving Medicare benefits based on disability when you reach age 65, your coverage continues with no interruption. However, the reason for your entitlement changes from disability to age. If you did not have Part B when you were disabled, you will automatically be enrolled in Part B when you turn age 65. If you were paying a Part B premium surcharge (penalty for late enrollment) while you were disabled, the surcharge will be dropped when you turn age 65.
  • True!
  • Yes, he should apply. He should not delay applying while he prepares for the process. If his application is approved, Social Security will automatically enroll Ramon in Medicare after he gets 2 years of disability benefits. SSA starts counting the 24 months from the month Ramon becomes entitled to disability benefits, not the month when he receives his first check. People with Amyotrophic Lateral Sclerosis (Lou Gehrig&apos;s disease) get Medicare beginning with the month they become entitled to disability benefits. Note to instructor: The scenario on this slide is meant to generate discussion about the application process and the necessary documents. Use if time permits and if appropriate.
  • Now, let’s discuss the health plan choices available for people entitled to Medicare because of a disability.
  • The same Medicare health plan choices are available to disabled beneficiaries as those available to beneficiaries 65 and older. They may choose the Original Medicare Plan or a Medicare Advantage plan, such as a Medicare Managed Care plan or a Private Fee-for-Service plan, if one is available in their area. However, there are some restrictions on eligibility for Medigap plans for people with a disability, as discussed in the session on Medigap coverage, Module 3.
  • In addition, Medicare coverage is the same as for people who are 65 and over. There are no special limitations on Medicare coverage based on a disability.
  • We’ve learned a lot about Medicare coverage for people who are disabled. Now let’s look at some additional information sources.
  • There are many information resources for disabled Medicare beneficiaries. Since eligibility is determined by Social Security status, the SSA 800 number or the local SSA office is often the first place to call. A Medicare customer service representative also can give you information or refer you to the proper agency. Your local State Health Insurance Assistance Program (SHIP) or State Office on Aging may have additional resources. The Internet also offers a wide variety of information sources for disabled Medicare beneficiaries and caregivers, at the following websites: www.ssa.gov/odhome/odhome.htm www.medicare.gov www.cms.hhs.gov
  • Let’s look at the key concepts we have covered in this lesson. We learned that the Social Security Administration determines if you are disabled and that you are eligible for Medicare after receiving 24 months of cash benefits in most cases. If you are entitled to Medicare because of a disability, you receive all the same benefits that you would receive if you were entitled because of age, and you can receive your benefits from the Original Medicare Plan or you may choose a Medicare Advantage plan.
  • Note to instructor: This slide concludes the regular lessons for this module. If you would like to cover more in-depth information, the remaining 17 slides discuss details on eligibility and the Ticket to Work provisions. It is recommended that you have experience in the Social Security determination process or have a subject matter expert present before continuing with this information.
  • For those of you who are interested, the remainder of Module 6 contains more detailed information about: The disability determination process, and Special Medicare provisions for disabled beneficiaries.
  • First, let’s talk about SSI. SSA pays Supplemental Security Income (SSI) for people who are 65 or older, or are blind, or have a disability, and who have little or no income or resources. You need not have worked under Social Security to qualify for SSI. SSI is not just for adults. Monthly payments can also be made for disabled or blind children. There is no minimum age. How much SSI you get depends on where you live. The basic SSI amount is the same nationwide. However, many states add money to the basic benefit. The amount of your income also determines the amount of your benefit. Generally, the more income you have, the lower your SSI benefit. However, not everything you get is considered income and not all income counts in determining your eligibility. Many people receive both Social Security and SSI benefits, if the amount of their Social Security benefit is low enough. For most adults, the medical requirements for disability payments are the same under both SSI and Social Security, and a person’s disability is determined by the same process. People who get SSI do not automatically qualify for Medicare. However, they usually do get food stamps and get Medicaid to help pay their doctor and hospital bills. In most cases, someone receiving as little as $1 in SSI is still eligible for Medicaid. You can call SSA at 1-800-772-1213 (TTY 1-800-325-0778) to find out the benefit amounts for your state and to get help in applying for benefits.
  • The other major program administered by SSA is Retirement, Survivors and Disability Insurance (RSDI), which is commonly known as Social Security benefits. Social Security benefits are intended to help replace earnings lost due to old age, disability or death. If you have worked in employment covered by Social Security, you may qualify for disability or retirement benefits based on your own earnings. In addition, certain members of your family may qualify for benefits based on your work. Benefit amounts are based on the worker’s lifetime average earnings covered by Social Security. If you are working and age 25 or older, you should be receiving an annual Social Security Statement explaining the amount of benefits for which you and your family may qualify based on your age and earnings. Only certain types of income, such as earnings from employment or self-employment, worker’s compensation, and some government benefits, may affect your Social Security eligibility or benefit amount. Most other types of income (VA, private pensions, annuities, interest, etc.) do not matter, regardless of the amount.
  • This slide shows the various types of RSDI benefits. You may qualify for disability and retirement benefits based on your own earnings, and certain family members also may qualify for benefits based on your work: Your spouse or widow(er), including some divorced spouses or widow(er)s Your dependent children, including adult children who have a disability that started before age 22 In some cases, your dependent parent Even if they receive Social Security cash benefits, your family members cannot qualify for Medicare unless they also meet the basic Medicare eligibility requirements for age, disability, or ESRD status.
  • You should apply for benefits as soon as you become disabled. You may file by phone, by mail, or by visiting any Social Security office. While you may receive benefits for months before your application was approved, they are limited to 1 year before the date you applied. Applications for disability benefits take more time to process than other types of Social Security claims--usually from 60 to 90 days. [The Disability Report—Adult—Form SSA-3368-BK, part of the application for benefits, is available online at www.ssa.gov/online/ssa-3368.pdf ]
  • As noted in the basic part of this module, once you apply for Social Security disability benefits, SSA will determine if you are eligible. First, the Social Security office will review your application to see if you meet the basic requirements for disability benefits. They look at whether you have worked long enough and recently enough, your age, and, if you are applying for benefits as a family member, your relationship to the worker. The office then will send your application to the Disability Determination Service (DDS) office in your state where the medical evaluation takes place. In many states, the DDS is part of the Vocational Rehabilitation office. The DDS will consider all the facts in your case and decide whether you are disabled under the Social Security law. They will use the medical evidence from your doctors and from hospitals, clinics, or institutions where you have been treated and all the other information they have for your case. On the medical report forms, your doctors or other sources are asked for a medical history of your condition: what is wrong with you; when it began; how it limits your activities; what the medical tests have shown; and what treatment you have received. They also are asked for information about your ability to do work-related activities, such as walking, sitting, lifting, carrying, and remembering instructions. Your doctors are not asked to decide if you are disabled. Only the DDS can make that decision.
  • The DDS may ask you to have a special examination called a consultative examination (CE) if they need more medical information before they can decide your case under Social Security law and rules. There are several reasons why the DDS might request a CE, or even more than one CE: If there isn&apos;t enough information to make a decision To resolve a conflict or ambiguity in your records When there is no treating source or when existing records are not available Your doctor, or the medical facility where you have been treated, is the preferred source to do this examination, but it may be done by someone else. Social Security will pay for the examination and for certain travel expenses related to it. A CE can be a physical or mental examination or test. It will not necessarily be a complete examination because the DDS may already have enough other information from your records. They will ask only for the specific examinations and tests they need to make a determination on your claim. The physician or psychologist is allowed to to use support staff to help perform the CE, but he or she is still responsible for reviewing what they did and for the report that is sent to the DDS.
  • The DDS uses a step-by-step process involving five questions to determine if you are disabled: 1. Are you working? If you are and your earnings average more than $810 a month, you generally cannot be considered disabled. If you are not working, the DDS goes to the next step. 2. Is your condition &amp;quot;severe&amp;quot;? For your claim to be considered, your condition must interfere with basic work-related activities. If it does not, the DDS will find that you are not disabled. If it does, they will go to the next step. 3. Is your condition found in the list of disabling impairments? The DDS uses a list of impairments that are so severe they automatically mean you are disabled. If your condition is not on the list, the DDS must decide if it is of equal severity to an impairment on the list. If it is, they will find that you are disabled. If it is not, they go to the next step. 4. Can you do the work you did previously? If your condition is severe, but not at the same severity as an impairment on the list, then the DDS must determine if it interferes with your ability to do the work you did previously. If it does not, your claim will be denied. If it does, they go to the next step. 5. Can you do any other type of work? If you cannot do the work you did in the past, the DDS will see if you are able to adjust to other work. They consider your medical conditions and your age, education, work experience, and any transferable skills you may have. If you cannot adjust to other work, your claim will be approved. If you can, your claim will be denied. Note: The decision process is different for people who are blind; call SSA to obtain additional information.
  • Once the DDS has reached a decision on your claim and SSA has checked to see if you meet the basic eligibility requirements, you will receive a letter. If your claim is approved, the letter will show the amount of your benefit and when payments start. If it is not approved, the letter will explain why and tell you how to appeal if you don&apos;t agree. You also may appeal if your claim is approved but you think your payments should begin earlier.
  • If your application is approved, your first benefit will be paid for the sixth full month after the date your disability began. For example, if SSA finds that your disability began on January 15, your first disability benefit (subject to 1 year retroactivity) will be for the month of July. Social Security benefits are paid in the month after the month for which they&apos;re due, so you would receive your July benefit in August. The amount of your monthly disability benefit is based on your lifetime average earnings covered by Social Security. Ordinarily, disability payments from other sources do not affect your Social Security disability benefits. However, if the disability payment is workers&apos; compensation or another public disability payment, your and your family&apos;s Social Security benefits may be reduced. Some people have to pay Federal income taxes on their Social Security benefits. This usually happens only if your total income is high. At the end of the year, you will receive a Social Security Benefit Statement (Form SSA-1099) showing the amount of benefits you received. Use the statement to complete your Federal income tax return if any of your benefits are subject to tax. For more information about this tax, ask the Internal Revenue Service for a copy of Publication 915. If you owe taxes on your Social Security benefits, you may choose to have Federal taxes withheld from your benefits.
  • If your claim is denied or you disagree with any part of the decision, you may appeal the decision. The Social Security office will help you complete the paperwork. You have 60 days to file an appeal, counting from the time you receive the letter with the decision. It is assumed that you will receive the letter within 5 days after the date on it, unless you can show that you received it later. For more information about appeals, ask for the fact sheet, The Appeals Process (Publication No. 05-10041).
  • In general your cash benefits will continue as long as you are disabled . However, SSA will review your case periodically to see if you are still disabled. The frequency of the reviews depends on the expectation of recovery. If medical improvement is &amp;quot;expected,&amp;quot; your case will normally be reviewed within 6 to 18 months. If medical improvement is &amp;quot;possible,&amp;quot; your case will normally be reviewed no sooner than 3 years. If medical improvement is &amp;quot;not expected,&amp;quot; your case may be reviewed no sooner than 7 years. What can cause benefits to stop? There are two things that can cause Social Security to decide that you are no longer disabled and to stop your benefits. Your benefits will stop if you work at a level considered &amp;quot;substantial.” Usually, average earnings of $810 or more a month are considered substantial. Your disability benefits also would stop if it is decided that your medical condition has improved to the point that you are no longer disabled. Your payments may be stopped temporarily if you refuse to accept vocational rehabilitation services, if you are convicted of a felony, or under certain other conditions, which SSA will explain. You must promptly report any improvement in your condition, if you return to work, and certain other events, as long as you are receiving benefits. These responsibilities are explained in the booklet you will receive when benefits start.
  • As noted on the previous slide, your entitlement to Part A will stop if SSA determines that your medical condition has improved to the point that you are no longer disabled. If you return to work and are still disabled, Part A coverage will normally end 8½ years after you return to work. Part A also ends with the month of your death. If you are buying Part A, your coverage may end for nonpayment of premiums or you may voluntarily stop your coverage by filing a written request. Your Part B entitlement ends with the month of your death, or for nonpayment of premiums, or, if you are under age 65, the month your Part A entitlement ends. You may also voluntarily end your Part B coverage by filing a written request. Part B (and Part A, if you are buying it) ends the last day of the month after the month you file the request to stop coverage. When Part A and/or Part B coverage ends because of nonpayment of premiums, the month of termination is based on the end of the grace period . Normally, the grace period for payment of premiums is the 90-day period following the month in which the initial premium bill was issued. The grace period may be extended for an additional 90 days if there is good cause for your failure to pay the premiums within the initial 90-day period.
  • The Ticket to Work and Work Incentives Improvement Act of 1999 (Ticket to Work) was passed by Congress to encourage people with disabilities to work without fear of losing their Medicare, Medicaid, or similar health benefits. The law addressed some specific situations that apply to Medicare beneficiaries who are disabled. We’re now going to discuss three of those provisions, including: Extending Medicare coverage for some working Medicare beneficiaries with disabilities Permitting suspension of Medigap insurance when covered under an Employer Group Health Plan (EGHP) Expanding options under the Medicaid program for workers with disabilities Let’s examine how each of these provisions affects beneficiaries.
  • Previously, disabled beneficiaries who returned to work and had earnings above the substantial gainful activity level, currently $810 per month, received 4 years of premium-free Medicare Part A. Ticket to Work extended the period for an additional 4½ years, effectively extending Medicare coverage from 4 to 8½ years. As was the case before Ticket To Work, if you successfully return to work and use up your entitlement to free Medicare Part A, you may buy Part A for as long as you continue to be disabled. If your income and resources are limited, you may be eligible for a program that helps pay your Medicare Part A monthly premium. This program is called the Qualified Disabled and Working Individuals Buy-In Program for Part A . To find out more about this program, call the QDWI contact in your state Medicaid agency.
  • Each Medicare supplement (Medigap) policy must provide for benefits and premiums to be suspended at the request of a person entitled to Medicare on the basis of a disability who becomes covered under an employer group health plan (EGHP). If you lose EGHP coverage and provide notice of the loss within 90 days, the Medigap policy must be automatically reinstated effective with the date the EGHP coverage ended.
  • Ticket to Work established two Medicaid buy-ins through the creation of optional eligibility groups of title II beneficiaries: The first allows states to offer buy-in to working-age individuals who, except for earnings, would be eligible for SSI benefits. States can set eligibility limits on assets and earned and unearned income. The second Medicaid buy-in permits states to continue coverage for working individuals with disabilities whose medical conditions remain severe, but who would otherwise lose eligibility due to medical improvement. For both buy-ins, states that impose premiums may require premiums or cost-sharing set on a sliding scale based on income. States must require payment of 100 percent of the premium from individuals whose adjusted gross income exceeds $75,000, except that a state may subsidize the premiums with unmatched state funds.
  • 2004 REACH National Medicare Training Program

    1. 1. 2004 REACH National Medicare Training Program
    2. 2. Medicare Entitlement Because of ESRD or Disability Module 6
    3. 3. Medicare for People with End-Stage Renal Disease Module 6 Lesson A
    4. 4. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>Health plan options </li></ul><ul><li>Information sources </li></ul>
    5. 5. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>Health plan options </li></ul><ul><li>Information sources </li></ul>
    6. 6. End-Stage Renal Disease <ul><li>Often referred to as ESRD </li></ul><ul><li>Kidney impairment </li></ul><ul><ul><li>Appears irreversible and permanent </li></ul></ul><ul><ul><li>Requires regular dialysis or a kidney transplant to maintain life </li></ul></ul>Overview
    7. 7. Medicare for People with ESRD <ul><li>Coverage began in 1973 </li></ul><ul><li>Over 1 million received life-saving therapy </li></ul><ul><ul><li>Dialysis </li></ul></ul><ul><ul><li>Transplant </li></ul></ul><ul><li>Over 350,000 receiving therapy </li></ul><ul><li>90,000 had successful kidney transplant </li></ul><ul><li>20,000 improved so much they left Medicare </li></ul>Overview
    8. 8. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>Health plan options </li></ul><ul><li>Information sources </li></ul>
    9. 9. Part A Eligibility Requirements <ul><li>Eligible for Medicare Part A at any age if </li></ul><ul><ul><li>Regular dialysis or </li></ul></ul><ul><ul><li>Kidney transplant </li></ul></ul><ul><li>AND at least one of the following </li></ul><ul><ul><li>Worked required amount of time </li></ul></ul><ul><ul><li>Receiving SSA or RRB cash benefits </li></ul></ul><ul><ul><li>Spouse or dependent child of someone who worked required amount of time </li></ul></ul>Eligibility and Enrollment
    10. 10. Part B Eligibility <ul><li>If entitled to Medicare Part A </li></ul><ul><ul><li>Can enroll in Part B </li></ul></ul><ul><ul><ul><li>Will have to pay Part B premium </li></ul></ul></ul><ul><li>Will need both Part A and Part B to cover certain services </li></ul><ul><li>For more information </li></ul><ul><ul><li>Call SSA at 1-800-772-1213 </li></ul></ul><ul><ul><li>Call RRB at 1-800-808-0772 </li></ul></ul>Eligibility and Enrollment
    11. 11. Enrollment <ul><li>Enroll at local SSA office </li></ul><ul><li>May delay enrollment if covered by GHP </li></ul><ul><li>Get the facts before deciding to delay </li></ul><ul><ul><li>Especially if transplant is planned </li></ul></ul><ul><li>If already enrolled in Part A </li></ul><ul><ul><li>May eliminate Part B surcharge </li></ul></ul>Eligibility and Enrollment
    12. 12. 30-Month Coordination Period <ul><li>During coordination period </li></ul><ul><ul><li>GHP pays first </li></ul></ul><ul><ul><li>Medicare pays second </li></ul></ul><ul><li>Begins when eligibility or entitlement begins </li></ul><ul><ul><li>Even if not enrolled in Medicare </li></ul></ul><ul><li>Medicare pays first after 30 months </li></ul><ul><li>New 30-month period begins if new period of Medicare coverage </li></ul>Eligibility and Enrollment
    13. 13. Enrollment Decision <ul><li>Can delay enrollment in Medicare (Part A and Part B) </li></ul><ul><li>Considerations in delaying </li></ul><ul><ul><li>Medicare could help pay deductibles and coinsurance </li></ul></ul><ul><ul><li>No Part B premium if you delay enrollment </li></ul></ul><ul><ul><li>Immunosuppressive drug therapy is covered </li></ul></ul><ul><ul><ul><li>If you were entitled to Part A at time of transplant and Medicare made payment for transplant OR </li></ul></ul></ul><ul><ul><ul><li>If Medicare made no payment, Medicare was secondary payer, AND you are enrolled in Part B at time of drug therapy </li></ul></ul></ul><ul><ul><ul><li>For as long as you have Medicare </li></ul></ul></ul>Eligibility and Enrollment
    14. 14. ESRD Coverage Begins <ul><li>Third month after the month dialysis begins </li></ul><ul><li>First month if certain conditions are met </li></ul><ul><li>Month you receive a kidney transplant </li></ul><ul><li>Month you are admitted to approved hospital </li></ul><ul><ul><li>For transplant or procedures preliminary to transplant </li></ul></ul><ul><li>2 months before month of transplant </li></ul><ul><ul><li>If transplant is delayed more than 2 months </li></ul></ul>Eligibility and Enrollment
    15. 15. Coverage Ends <ul><li>If ESRD is the ONLY reason you were entitled </li></ul><ul><li>12 months after month you no longer require maintenance dialysis </li></ul><ul><li>OR </li></ul><ul><li>36 months after month of kidney transplant </li></ul>Eligibility and Enrollment
    16. 16. Coverage Continues or Resumes <ul><li>If dialysis is resumed </li></ul><ul><ul><li>OR </li></ul></ul><ul><li>Another transplant is received </li></ul>Eligibility and Enrollment
    17. 17. Let’s see what we know… <ul><li>Your 30-month coordination period begins when your eligibility or entitlement begins, even if you are not enrolled in Medicare. </li></ul><ul><li>True or False? </li></ul>
    18. 18. Here is a case study… <ul><li>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? </li></ul>
    19. 19. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><ul><li>Dialysis patients </li></ul></ul><ul><ul><li>Transplant patients </li></ul></ul><ul><li>Health plan options </li></ul><ul><li>Information sources </li></ul>
    20. 20. Benefits <ul><li>All services covered by Original Medicare </li></ul><ul><ul><li>Medicare Part A </li></ul></ul><ul><ul><li>Medicare Part B </li></ul></ul><ul><li>Special services for </li></ul><ul><ul><li>Dialysis patient </li></ul></ul><ul><ul><li>Transplant patient </li></ul></ul><ul><ul><ul><li>Including immunosuppressive drugs </li></ul></ul></ul><ul><ul><ul><ul><li>Certain conditions must be met </li></ul></ul></ul></ul>Coverage
    21. 21. Covered Services <ul><li>Inpatient dialysis treatments </li></ul><ul><li>Home dialysis training </li></ul><ul><li>Self-dialysis training </li></ul><ul><li>Home dialysis equipment and supplies </li></ul><ul><li>Certain home support services </li></ul><ul><li>Certain drugs for home dialysis </li></ul>Coverage for Dialysis Patients
    22. 22. Ambulance Services <ul><li>Transportation to dialysis facility </li></ul><ul><ul><li>Covered only if other forms of transportation would be harmful to your health </li></ul></ul><ul><ul><li>Ambulance supplier must get written order </li></ul></ul><ul><li>For information </li></ul><ul><ul><li>1-800-MEDICARE (1-800-633-4227) </li></ul></ul><ul><ul><ul><li>TTY/TDD 1-877-486-2048 </li></ul></ul></ul>Coverage for Dialysis Patients
    23. 23. Home Dialysis <ul><li>Types of dialysis that can be performed at home </li></ul><ul><ul><li>Hemodialysis </li></ul></ul><ul><ul><li>Peritoneal dialysis </li></ul></ul><ul><li>Most common drugs covered by Medicare </li></ul><ul><ul><li>Heparin </li></ul></ul><ul><ul><li>Antidote for heparin when necessary </li></ul></ul><ul><ul><li>Topical anesthetics </li></ul></ul><ul><ul><li>Epogen® or Epoetin alfa </li></ul></ul>Coverage for Dialysis Patients
    24. 24. Services NOT Covered <ul><li>Paid dialysis aides </li></ul><ul><li>Lost pay </li></ul><ul><li>Place to stay during your treatment </li></ul><ul><li>Blood for home dialysis </li></ul><ul><ul><li>Unless part of doctor’s service or needed to prime the dialysis equipment </li></ul></ul><ul><li>Transportation to the dialysis facility </li></ul><ul><ul><li>Except in special cases </li></ul></ul>Coverage for Dialysis Patients
    25. 25. Medicare Part A <ul><li>Covers inpatient hospital services for kidney transplant </li></ul><ul><ul><li>Transplant </li></ul></ul><ul><ul><li>Preparation for transplant </li></ul></ul><ul><ul><li>Kidney Registry fee </li></ul></ul><ul><ul><li>Laboratory tests </li></ul></ul><ul><ul><li>Full cost of care for donor </li></ul></ul><ul><ul><ul><li>Including care needed due to complications </li></ul></ul></ul>Coverage for Transplant Patients
    26. 26. Medicare Part B for Kidney Transplant <ul><li>Surgeon’s services </li></ul><ul><li>Doctor’s services to donor </li></ul><ul><ul><li>No deductible </li></ul></ul><ul><li>Immunosuppressive drug therapy </li></ul><ul><ul><li>If entitled to Part A at time of transplant and </li></ul></ul><ul><ul><ul><li>Medicare paid for transplant OR </li></ul></ul></ul><ul><ul><ul><li>Medicare made no payment but was secondary payer </li></ul></ul></ul>Coverage for Transplant Patients
    27. 27. Coverage for Blood <ul><li>Part A and Part B can help pay for </li></ul><ul><ul><li>Whole blood </li></ul></ul><ul><ul><li>Units of packed red blood cells </li></ul></ul><ul><ul><li>Blood components </li></ul></ul><ul><ul><li>Cost of blood processing and administration </li></ul></ul><ul><li>Part A and/or Part B deductible must be met </li></ul>Coverage for Transplant Patients
    28. 28. Immunosuppressive Drugs <ul><li>Used to reduce the risk of rejection </li></ul><ul><li>Taken for the rest of your life </li></ul><ul><li>No time limit if eligible for Medicare because of age or disability </li></ul><ul><li>Must have Part B at time of dispensing of drug </li></ul>Coverage for Transplant Patients
    29. 29. Immunosuppressive Drugs <ul><li>If you have Medicare only because of ESRD, Medicare will pay for immunosuppressive drug therapy if </li></ul><ul><ul><li>You were entitled to Part A at time of transplant and </li></ul></ul><ul><ul><ul><li>Medicare paid for the transplant OR </li></ul></ul></ul><ul><ul><ul><li>If Medicare made no payment, Medicare was secondary payer </li></ul></ul></ul><ul><li>AND </li></ul><ul><ul><li>You are enrolled in Part B at time of drug therapy </li></ul></ul>Coverage for Transplant Patients
    30. 30. Let’s see what we know… <ul><li>Which service is covered by Medicare? </li></ul><ul><ul><li>Paid dialysis aides </li></ul></ul><ul><ul><li>Lost pay </li></ul></ul><ul><ul><li>Kidney Registry fee </li></ul></ul>
    31. 31. Let’s look at a case study… <ul><li>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? </li></ul><ul><li>What are some important points for someone who may be having an organ transplant? </li></ul>
    32. 32. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>Health plan options </li></ul><ul><li>Information sources </li></ul>
    33. 33. Original Medicare <ul><li>Usually the only choice </li></ul><ul><li>Always an option </li></ul>Health Plan Options
    34. 34. Medicare Advantage Plans <ul><li>Usually not an option for those with ESRD </li></ul><ul><li>May stay in a plan if already in </li></ul><ul><li>May be able to join after kidney transplant </li></ul><ul><li>May join another if your plan leaves </li></ul><ul><li>May “age in” </li></ul>Health Plan Options
    35. 35. If Your Plan Leaves Medicare <ul><li>You have options </li></ul><ul><ul><li>Can return to the Original Medicare Plan </li></ul></ul><ul><ul><li>Can join another Medicare Advantage plan if available in your area </li></ul></ul><ul><ul><ul><li>If your plan left on or after December 31, 1998 </li></ul></ul></ul>Health Plan Options
    36. 36. <ul><li>People with Medicare who are entitled because of ESRD can receive both Part A and Part B services. </li></ul><ul><li>True or False? </li></ul>Let’s see what we know…
    37. 37. Let’s look at a case study… <ul><li>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. </li></ul>
    38. 38. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Coverage </li></ul><ul><li>Health plan options </li></ul><ul><li>Information sources </li></ul>
    39. 39. ESRD Networks <ul><li>Ensure administration of ESRD benefits </li></ul><ul><li>Develop quality standards </li></ul><ul><li>Assess treatment modalities </li></ul><ul><li>Provide technical assistance to dialysis facilities </li></ul><ul><li>Educate beneficiaries </li></ul><ul><li>Contact information: Local phone number </li></ul>Information Sources
    40. 40. ESRD Information Sources <ul><li>American Association of Kidney Patients </li></ul><ul><ul><li>1-800-749-2257 </li></ul></ul><ul><li>National Kidney Foundation </li></ul><ul><ul><li>1-800-622-9010 </li></ul></ul><ul><li>American Kidney Fund </li></ul><ul><ul><li>1-800-638-8299 </li></ul></ul>Information Sources
    41. 41. www.medicare.gov <ul><li>Dialysis Facility Compare </li></ul><ul><ul><li>Searchable database </li></ul></ul><ul><ul><li>Facility location </li></ul></ul><ul><ul><li>Treatment choices offered </li></ul></ul><ul><ul><li>Ownership </li></ul></ul><ul><ul><li>Availability of evening services </li></ul></ul><ul><ul><li>Quality measures </li></ul></ul>Information Sources
    42. 42. www.medicare.gov <ul><li>Quality measures for dialysis facilities </li></ul><ul><ul><li>How well facility treats patients </li></ul></ul><ul><ul><li>Getting the best possible results </li></ul></ul><ul><li>Some quality measures </li></ul><ul><ul><li>Percent of patients adequately dialyzed </li></ul></ul><ul><ul><li>Percent whose anemia is adequately managed </li></ul></ul><ul><ul><li>Patient survival information </li></ul></ul>Information Sources
    43. 43. Key Concepts <ul><li>Most people with ESRD are eligible for Medicare </li></ul><ul><li>It is important to understand enrollment options </li></ul><ul><li>People with ESRD receive </li></ul><ul><ul><li>All Part A and Part B services </li></ul></ul><ul><ul><li>Some additional services </li></ul></ul><ul><li>Original Medicare Plan is usually only choice </li></ul><ul><li>More information is available </li></ul>
    44. 44. Medicare Entitlement Because of a Disability Module 6 Lesson B
    45. 45. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Health plan choices </li></ul><ul><li>Information sources </li></ul>
    46. 46. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Health plan choices </li></ul><ul><li>Information sources </li></ul>
    47. 47. Coverage for Disabled Beneficiaries <ul><li>Coverage began in 1973 </li></ul><ul><li>1.7 million beneficiaries initially </li></ul><ul><li>5.6 million in 2001 </li></ul><ul><ul><li>14% of all Medicare beneficiaries </li></ul></ul>Overview
    48. 48. Medicare Enrollment Trend Overview
    49. 49. Social Security and Medicare <ul><li>Relationship between Social Security and Medicare </li></ul><ul><ul><li>Medicare is title XVIII of SS Act </li></ul></ul><ul><ul><li>Medicare based on entitlement to SS benefits </li></ul></ul><ul><ul><li>Amendments expanded Medicare to cover </li></ul></ul><ul><ul><ul><li>Disabled persons under 65 entitled to SS benefits for 24 months </li></ul></ul></ul>Overview
    50. 50. Disability Defined <ul><li>Social Security definition </li></ul><ul><ul><li>Inability to work </li></ul></ul><ul><ul><li>Will last for 1 year or result in death </li></ul></ul><ul><ul><li>Can be the result of blindness </li></ul></ul><ul><ul><ul><li>Visual acuity 20/200 or less with correcting lens in better eye </li></ul></ul></ul><ul><ul><ul><li>OR </li></ul></ul></ul><ul><ul><ul><li>Visual field of 20 degrees or less </li></ul></ul></ul>Overview
    51. 51. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Enrollment process </li></ul><ul><li>Health plan choices </li></ul><ul><li>Information sources </li></ul>
    52. 52. SSA Programs <ul><li>RSDI </li></ul><ul><ul><li>Based on covered earnings </li></ul></ul><ul><ul><li>Funded by FICA </li></ul></ul><ul><li>SSI </li></ul><ul><ul><li>Based on need </li></ul></ul><ul><ul><li>Funded by general revenues </li></ul></ul><ul><li>Both pay benefits for people with disabilities </li></ul>Eligibility and Enrollment
    53. 53. Qualifying for Medicare <ul><li>Usually begins after 24 months of benefits </li></ul><ul><li>Exceptions </li></ul><ul><ul><li>Begins first month for ALS </li></ul></ul><ul><ul><li>No 5-month waiting period for cash benefits </li></ul></ul><ul><ul><ul><li>Childhood disability beneficiaries </li></ul></ul></ul><ul><ul><ul><li>Some people previously entitled to disability benefits </li></ul></ul></ul>Eligibility and Enrollment
    54. 54. Qualifying for Disability Benefits <ul><li>Meet requirements for SSA disability benefits </li></ul><ul><li>5-month waiting period before cash benefits begin </li></ul>Eligibility and Enrollment
    55. 55. Applying for Disability Benefits <ul><li>Take your </li></ul><ul><ul><li>Social Security Number </li></ul></ul><ul><ul><li>Proof of age </li></ul></ul><ul><ul><li>Medical care provider information </li></ul></ul><ul><ul><li>Medical treatment information </li></ul></ul><ul><ul><li>Medical records, if available </li></ul></ul><ul><ul><li>Work history information </li></ul></ul><ul><ul><li>Most recent W-2 or self-employment tax return </li></ul></ul>Eligibility and Enrollment
    56. 56. Enrollment in Medicare <ul><li>Automatic enrollment in Original Medicare </li></ul><ul><ul><li>After 24 months of disability payments </li></ul></ul><ul><ul><ul><li>Except for ALS </li></ul></ul></ul><ul><ul><li>Will receive card by mail </li></ul></ul><ul><ul><ul><li>Call SSA if it doesn’t arrive </li></ul></ul></ul><ul><ul><li>Decide on Part B </li></ul></ul>Eligibility and Enrollment
    57. 57. Continuing Medicare Entitlement <ul><li>Ends when SSA determines you are no longer disabled </li></ul><ul><li>Continues for working beneficiaries who are still disabled </li></ul><ul><ul><li>8½ years premium-free Part A </li></ul></ul><ul><ul><li>May purchase coverage afterward </li></ul></ul><ul><li>Entitlement reason changes at age 65 </li></ul>Eligibility and Enrollment
    58. 58. Let’s see what we have learned... <ul><li>Most people who are receiving cash benefits for a disability are eligible for Medicare after 24 months. </li></ul><ul><li>True or False ? </li></ul>
    59. 59. Here is a case study… <ul><li>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? </li></ul>
    60. 60. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Health plan choices </li></ul><ul><li>Information sources </li></ul>
    61. 61. Choices <ul><li>All Medicare plans available </li></ul><ul><ul><li>Original Medicare Plan </li></ul></ul><ul><ul><li>Medicare Advantage plans </li></ul></ul><ul><ul><ul><li>Medicare Managed Care plans </li></ul></ul></ul><ul><ul><ul><li>Private Fee-for-Service plans </li></ul></ul></ul><ul><li>Some restrictions on eligibility for Medigap </li></ul>Health Plan Choices
    62. 62. Coverage <ul><li>Coverage same as for people 65 and over </li></ul><ul><li>All Medicare covered benefits </li></ul><ul><li>No special limitations </li></ul>Health Plan Choices
    63. 63. Session Topics <ul><li>Overview </li></ul><ul><li>Eligibility and enrollment </li></ul><ul><li>Health plan choices </li></ul><ul><li>Information sources </li></ul>
    64. 64. If You Want to Know More… <ul><li>SSA 1-800-772-1213 (TTY 1-800-325-0778) </li></ul><ul><li>1-800-MEDICARE (TTY 1-877-486-2048) </li></ul><ul><li>SHIP </li></ul><ul><li>State Office on Aging </li></ul><ul><li>Internet </li></ul><ul><ul><li>www.ssa.gov </li></ul></ul><ul><ul><li>www.medicare.gov </li></ul></ul><ul><ul><li>www.cms.hhs.gov </li></ul></ul>Information Sources
    65. 65. Key Concepts <ul><li>SSA determines disability </li></ul><ul><li>Eligible for Medicare if you receive cash benefits </li></ul><ul><li>Receive all benefits </li></ul><ul><li>Eligible for all health care choices </li></ul>
    66. 66. Thanks for your attention!
    67. 67. <ul><li>Medicare Entitlement </li></ul><ul><li>Because of a Disability </li></ul><ul><li>Detailed Information </li></ul>
    68. 68. Supplemental Security Income (SSI) <ul><li>Based on financial need </li></ul><ul><li>Must be 65 or over, or blind, or disabled </li></ul><ul><ul><li>Children may be eligible </li></ul></ul><ul><li>Benefits reduced for other income </li></ul><ul><li>Call SSA at 1-800-772-1213 for more information </li></ul>
    69. 69. Social Security Benefits (RSDI) <ul><li>Based on covered earnings </li></ul><ul><li>Worker and certain family members may qualify </li></ul><ul><ul><li>See Social Security Statement for estimates </li></ul></ul><ul><li>Only certain types of income affect benefits </li></ul>
    70. 70. Social Security Benefits (RSDI) <ul><li>Retirement benefits for yourself and your </li></ul><ul><ul><li>Husband or wife </li></ul></ul><ul><ul><li>Dependent children </li></ul></ul><ul><li>Survivors benefits for your </li></ul><ul><ul><li>Widow or widower </li></ul></ul><ul><ul><li>Dependent children </li></ul></ul><ul><ul><li>Parents </li></ul></ul><ul><li>Disability benefits for yourself and your </li></ul><ul><ul><li>Husband or wife </li></ul></ul><ul><ul><li>Dependent children </li></ul></ul>
    71. 71. Applying for Disability Benefits <ul><li>Apply as soon as you become disabled </li></ul><ul><ul><li>1-year limit on retroactive benefits </li></ul></ul><ul><li>Call 1-800-772-1213 or visit any SSA office </li></ul><ul><ul><li>TTY number 1-800-325-0778 </li></ul></ul><ul><li>Decision generally takes 60 to 90 days </li></ul>
    72. 72. Disability Determination Service <ul><li>State agency </li></ul><ul><li>Determines disability under Social Security law </li></ul><ul><li>Considers </li></ul><ul><ul><li>Medical evidence </li></ul></ul><ul><ul><li>Medical report forms </li></ul></ul><ul><ul><li>Other information as necessary </li></ul></ul>
    73. 73. Consultative Examination <ul><li>When the DDS needs more medical information to decide your case </li></ul><ul><li>Your doctor or medical facility is preferred </li></ul><ul><li>Social Security pays for the exam and travel expenses </li></ul><ul><li>May not be a complete examination </li></ul>
    74. 74. Process for Determining Disability <ul><li>Step-by-step process involving 5 questions </li></ul><ul><ul><li>Are you working? </li></ul></ul><ul><ul><li>Is your condition “severe”? </li></ul></ul><ul><ul><li>Is your condition on list of disabling impairments? </li></ul></ul><ul><ul><li>Can you do your previous work? </li></ul></ul><ul><ul><li>Can you do any other type of work? </li></ul></ul>
    75. 75. Disability Decision <ul><li>Sent in a letter </li></ul><ul><li>If approved, letter shows </li></ul><ul><ul><li>Benefit amount </li></ul></ul><ul><ul><li>Date payments start </li></ul></ul><ul><li>If disapproved, letter explains </li></ul><ul><ul><li>Reason for denial </li></ul></ul><ul><ul><li>How to appeal </li></ul></ul>
    76. 76. If Claim Is Approved <ul><li>Social Security benefits will be paid </li></ul><ul><ul><li>After 5 full months </li></ul></ul><ul><li>Amount of benefit based on lifetime average earnings </li></ul><ul><li>Other payments may reduce benefit amount, e.g., Worker’s Compensation </li></ul><ul><li>Cash benefits may be taxed </li></ul>
    77. 77. If Claim Is Denied <ul><li>May appeal any part of decision </li></ul><ul><li>Must appeal within 60 days </li></ul><ul><li>Social Security provides assistance </li></ul>
    78. 78. Status of Cash Benefits <ul><li>Case is reviewed periodically </li></ul><ul><ul><li>Frequency depends on expectation of recovery </li></ul></ul><ul><li>Benefits continue based on disability status </li></ul><ul><li>Cash benefits may stop if: </li></ul><ul><ul><li>Earn $810 or more a month </li></ul></ul><ul><ul><li>Medical condition improves and no longer disabled </li></ul></ul>
    79. 79. Termination from Medicare <ul><li>Entitlement to Part A ends </li></ul><ul><ul><li>Month of death </li></ul></ul><ul><ul><li>Under 65 and no longer disabled </li></ul></ul><ul><ul><li>Nonpayment of Part A premiums </li></ul></ul><ul><ul><li>Voluntary termination (if buying Part A) </li></ul></ul><ul><ul><li>Working, after 8½ years of premium-free Part A </li></ul></ul><ul><li>Entitlement to Part B ends </li></ul><ul><ul><li>Month of death </li></ul></ul><ul><ul><li>Month Part A entitlement ends if under age 65 </li></ul></ul><ul><ul><li>Nonpayment of Part B premiums </li></ul></ul><ul><ul><li>Voluntary termination </li></ul></ul>
    80. 80. Ticket to Work Provisions <ul><li>Medicare coverage for some disabled working beneficiaries </li></ul><ul><li>Suspension of Medigap for EGHP </li></ul><ul><li>State Medicaid options on paying premiums for workers with disabilities </li></ul>
    81. 81. (1) Extending Medicare Disability Benefits <ul><li>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 </li></ul>
    82. 82. (2) Suspending Medigap When Covered by Group Plan <ul><li>Beneficiaries entitled to Medicare because of disability can suspend Medigap while covered under an EGHP </li></ul><ul><li>Can reinstate Medigap by giving notice of loss of coverage within 90 days </li></ul>
    83. 83. (3) Expanding State Medicaid Options <ul><li>Working individuals with disabilities have increased opportunities to maintain Medicaid coverage </li></ul>
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