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MGH Abdominal Transplant ProgramOctober 5, 2016
!Eligibility Sufficient WorkingQuarters Social Security Taxes!Entitlement1.2.3.4.65SSDILou Gehrig’s DiseaseESRD! Dialysis! Kidney transplant
!Entitled vs. EnrolledEntitlementMedicare Entitled means thepatient CAN enroll!EnrolledMedicare Enrollment meansthe patient HAS coverage(elected and paid premium)Enrollment Window: Patients have 30 months of an enrollment window oncethey are entitled to Medicare based on ESRD Example:! Ellen starts hemodialysis on 5/15/2016.! She is entitled to Medicare beginning on 8/1/2016.! She can enroll in Medicare anytime between 8/1/2016 and2/28/2019.
Entitlement ReasonWhen Can MedicareStart?NotesHemodialysis3 Month WaitingPeriodMedicare can becomeactive on the 1st of the 4thmonth of long termdialysisPeritoneal DialysisNo waiting periodMedicare can becomeactive on the 1st of themonth in which trainingwas providedKidney TransplantNo waiting period if notpreviously on dialysisor within theirenrollment windowMedicare can becomeactive on the 1st of themonth in which kidneytransplant occurs(paperwork done aftertransplant, coverageretroactive)
Deductible DaysCopay DaysLifetime Reserve Days603060 1,288 deductiblePer benefit period 322 copay per day 644 copay per dayDays replenish after benefit period* concludesDays do not replenishonce used*Benefit Period Begins: Day of an Inpatient AdmissionBenefit Period Ends: 60 Days after day of dischargewww.medicare.gov
PremiumDeductibleCoverage 121.80 16680%MonthlyOne time calendar yearpaymentCan not exhaustMedicare B coveragePremium: 121.80 *Immunosuppressant Medications covered at 80%- IF Medicare A was active at the time of transplantwww.medicare.gov
Medicare and ESRD Review Missing Enrollment Window– Pa3ents who do not enroll within the 30 months: Must wait for Open Enrollment (January of each year, with benefitsbeginning in July of that year). Risk their commercial insurance refusing to pay as primary and onlycovering 20%. Will likely not have coverage to cover living donor complica3ons for thedonor’s life3me if not ac3ve at the 3me of transplant– Enrolling in Medicare A Only Pa3ents may elect A only, but they will have to wait for GeneralEnrollment for Part B even if they are in the en3tlement 30 monthwindow
Medicare Coordina3on of Benefits When a pa3ent has both Medicare and aCommercial Insurance, there are rules as towho pays first and who pays second Commercial Insurance Medicare– For the first 30 months of en3tlement,Commercial Insurance pays primary Regardless of Employment Status or if plan is COBRA– ATer 30 months Medicare becomes Primary
Medicare En3tlement due to ESRD DiagramPrimary: CommercialSecondary: Medicare*Start ofEn3tlement*Primary: MedicareSecondary: Commercial31st month1. HD (3-month wai3ng period)/PD/Preemp3ve (kidney transplant without dialysis)2. Medicare en3tlement ONLY due to ESRD lasts 36-months post-kidney transplant.3. Enroll into Medicare Parts A and B with the 2728 Form.
Medicare Part DYour Plan Pays:You Pay: 320 0Phase I:Deductible 320100% aftercopayments listed onright.Generic 35%Brand: 55%Retail:Phase II:Coinsurance / Copayments 320- 3310Mail Order:Specialty: 33%Phase III:Coverage Gap / Donut Hole 3311 – Out of Pocket Cost* of 4,85095% or thebalance minus 2.65 or 6.60Phase IV:Catastrophic Coverage 4,851 - remainder of the calendar yearGenerics 58%Brand: 45%5% of the totalcost or 2.95 / 7.40 whicheveris greater
Program NameIncome LimitPhone #WebsiteNotesSocial Security LowIncome SubsidyIndividual: 1,505Married: icare/prescriptionhelp/MedicareRecipients OnlyAsset Limit: 13,640 (indiv) or 27,250 (married)MassHealthIndividual: 1,317Married: artments/masshealth/MA Residents /insurance/moreprograms/health-safety-net/MA Residents only---------------Must use MGH /Community HealthCenter lthcare/prescriptionadvantage/Health Safety NetPrescriptionAdvantageIndividual: 1,485Married: 2,003MedicareIndividual: 4,950Married: 6,675Non Medicare:Individual: 1,861Married: 2,510MA Residents only
Program tanceProgramsIncome LimitIndividual: 3,960Married: 5,340VariesPhone ation.orgEligible forMedicare Recipientsonly at this time------------Also offerspremium assistancewww.needymeds.orgMany Medicarerecipients noteligible, butexceptions made
Fundraising can help cover the costs for Premiums Travel / Lodging Copays and Deductibles Meal costs Some caregiver and living expenses Help Hope Live and NFT are 503(c) charities Money is kept in an account just for you Reimburse you as you incur medical expenses Donors and Business can get a tax write off for donating money orresources Money is with you forever
!!!MA Health Connector Sells Individual DentalPlansOpen Enrollment Nov 1, 2016 – Jan 31, 2017Costs: Premiums vary from 25 – 55 per month Annual Max of 1,250 in Dental Coverage
Liver TransplantKate BerryPhone: 617-643-6794Fax: 617-643-0433Email: kberry3@partners.orgKidney TransplantSamuel KorPhone: 617-643-0767Fax: 617-643-0433Email: skor@partners.org
Ellen starts hemodialysis on 5/15/2016. ! She is entitled to Medicare beginning on 8/1/2016. ! She can enroll in Medicare anytime between 8/1/2016 and 2/28/2019. Entitlement Enrolled Medicare Entitled means the patient CAN enroll Medicare Enrollment means the patient
