Dialysis and Medicare

[DevonTexas]

I just finished posting about Dialysis and Medicare on my blog site. I tried to boil it down to a brief that covers the salient points about Medicare for Dialysis Patients. See http://devontexas.wordpress.com/2012...-and-medicare/


I hope this is helpful.

Devon

[putter77]

You need to check your links as they dont work!

[stumpr54]

Hello putter77,

What do you need to know about ESRD and Medicare? I started HHD in July 2012 and became eligible for Medicare Parts A and B as of July 1, 2012 because of HHD training and the start of hemodialysis. Had I gone in-center, my eligibility would have been delayed by 3 months. Half-way through 2012, I had already burned through the bulk of my employer's medical insurance max out of pocket, so paying Medicare premiums would have provided no financial benefit. That changed in 2013 with a fresh start and carrying Medicare as a secondary provider spared me from a $3500 out of pocket max, which was met during the first month on HHD in 2013 - in return for an annualized Medicare Part B premium of $1258.80 - an excellent return on my investment.

There is a vast amount of misinformation out there regarding Medicare Part A & B benefits for ESRD sufferers, which is remarkable given that the benefits have been mandated through changes in Medicare put in place in 1972!!! You can speak to Medicare representatives and most don't have a clue, as well as members of the medical profession. This is why DaVita has regional insurance specialists that advise dialysis center/clinic social workers and patients That advise was invaluable in my decision to pursue Medicare Part B. There is a 30 month Coordination of Benefits period that begins with the start of coverage eligibility, e.g. start of HHD training and dialysis or 90 days after starting in-center dialysis. During that period, your employer's or your individual health insurance is primary and Medicare is secondary. After this period, Medicare becomes primary and employer's/individual insurance becomes secondary. If you are under 65, and not eligible for Medicare based on age, you can expect the medical providers to screw up the precedence of the coverages - assuming if you have Medicare, it is always primary. I dealt with chonic errors in this regard through most of 2013 - my first year of Medicare coverage as a secondary insurer.

[putter77]

Thanks for info Questions about HD

Thank-You for this info.I did find out our ins covers 80/20 and hardgoods too.
Also have read medicare can be filed for at any age if you are ESRF and have documentation.
Im hoping they would cover the 20% our ins does not or our deductible of $1500.
I have been disabled with osteoarthritis and diabetes for many years but was turned down by SSI disability
even though their doctor said I was truly disabled.I had MRI and documents to prove it.

I want you to know you are very appreciated how you share on here with current info about HD.
I have always been told I have tiny veins (since age 19) and if they put me on HD I fear its a problem.
Why dont they use buttonholes on everyone from the start if that is the best way to go for HD?

Thanks for listening!

Putter*avatar exp.jpg

[stumpr54]

Hello putter77,

I addressed the question about the general absence of the use of buttonhole access for in-center hemodialysis treatments in an earler post, but I will repeat my observations.

While buttonhole site access in a fistula carries a vastly reduced risk of infliltration and general trauma to the fistula as well, the virtual elimination of the discomfort assoiciated with needle placement and reduced pressure hold times to stop bleeding owed to the tract that is present in the tissue between the skin and the fistula flap, it takes more more time to prepare/clean the site before needle insertion and because of the cleaning requirement - removal of scab and other tissue that can cover the site, there is an increased risk of infection.

The increased preparation time and infection risk are the key reasons why dialysis centers generally discourage the use of buttonholes. I have had in-center dialysis performed at 5 different DaVita clinics around the country and in each case when asked about their patients and the use of buttonholes the answer was very few to none. In fact, during my last experience at DaVita's Hospital Hill Dialysis center in downtown Kansas City, MO, I had an audience in several of the nurses and dialysis techs when I came in for my dialysis treatment. They had never seen a patient self-cannulate with blunt dialysis needles and via buttonhole access. Clearly, buttonholes are preferred by and for home hemodialysis patients, where time is not an issue and the additional steps in reducing the chance of infection nicely compensate for the convenience and comfort of this cannulation technique.

[kcramer]

putter77-Our center has one tech each shift that can do buttonholes. My tech is the only one who touches my arm at this point because of the difficulty I have had getting started. They just did a transposition and the head nurse for the clinic wants me to be independent and have me learn to cannulate myself. We will see if that happens. I do want to be in more control of my dialysis and have learned all I can, I keep asking questions to the education nurse who comes by my chair each week. She thinks I know a lot because as a retired teacher I keep learning and like to be on control. I feel so out of control when others have to do for me.

[happy0270]

Could someone help me understand if there is a way for someone who does not qualify for Medicaid due to retirement income who is only $2170 get double coverage? I was told due to ESRD no insurance will accept the application. Humana PPO is primary and a secondary insurance is very much needed to pick up the 20% that amounts to more than $5000 now. Thank you in advance!

[stumpr54]

Hello happy0270,

Anyone who has ESRD and is on dialysis, is eligible for Medicare. Medicare premiums with a monthly income of $2170 would be $104.90. Eligibility begins after the third month on in center dialysis or the first day of the first month of home hemodialysis training.

I became eligible on July 1, 2012 when I started HHD training on July 16, 2012. I did not elect to start Medicare B, which covers non-hospitalization medical costs not including any medications (Part C) and is what is paid for with the monthly premiums. I was and still work full time, and have my employer's medical insurance as primary and Medicare as secondary.

I started Medicare Part B on 1-1-13 and my employer's insurance deductible of $1600 and out of pocket max of $3500 were covered by Medicare Part B, e.g. no out of pocket medical expenses in return for the just under $1258.80/year Medicare Part B premiums. Those premiums remained unchanged in 2014 but my employer's medical insurance deductible increased to $2000 and out of pocket max to $4000. Once again, with Medicare Part B as my secondary insurer, I have paid nothing out of pocket other than the premiums for my employer's insurance plan and Medicare Part B. Compare the $2517.60 in Medicare Part B premiums for 2013 and 2014 to the $7500 in out of pocket expense for my employer's insurance, and a nearly 3 to 1 financial payback on the investment. Unfortunately, I have to be on dialysis full time to work this, and this arrangement is only good for 30 months from the start of Medicare eligibility. As of 1-1-15, my employer's insurance becomes secondary and Medicare becomes primary. At that point, whatever Medicare does not cover, e.g. 20% of eligible expenses, would then be subject to my employer's insurance deductible of $2000 and out of pocket max of $4000, if things stay the same in 2015.

Medicare reimbursement rates are a fraction of most private insurance and providers know this and tailor their services accordingly. My employer's insurance reimbursement for a single HHD treatment is $760. This is after insurance discount of $4068 against a claim amount of $4828. I have read that the Medicare amount paid for an in-center hemodialysis treatment is about 1/3 of this amount or $250. The Medicare reimbursement amount for an HHD treatment may be higher, but I'm certain it is not close to $760.

What this translates to is DaVita (HHD provider) will go after me for the 20% copay ($50/treatment, from the Medicare as primary coverage, will go unpaid by my employer's insurance until the deductible of $2000 is met, or 40 treatments, roughly two months, and then I will pay 15% of the $50 copay (267 treatments) until I reach the annual $4000 out of pocket max. Clearly, I will have more year than I have treatments with the $4000 out of pocket max at the Medicare reimbursement and copay rate covering the cost of 307 treatments, and I will only perform 260 treatments. Of course, I've got medications and other medical specialists thrown into the annual mix to help eat up the combined deductible and out of pocket max.

Regrettably, the Medicare Part B premiums beyond the 30 month Coordination of Benefits (COB) period (employer's insurance as primary and Medicare as secondary) at this point become a poor investment, bumping my overall out of pocket max to $5258.80 (Medicare Part B premiums, plus employer's insurance out of pocket annual max of $4000). The terms of the COB period require that the order of insurances switch after 30 months and remain in this order as long as I am covered by my employer's insurance. I cannot "drop" either coverage, in order to save myself whatever monies are to saved in premiums.

At this pace, I will have consumed the $4982.40 savings assoicated with 30 month COB period close to the end of 2015, or in less than one year and can expect annual out of pocket expenses from both employer and Medicare coverage to meet or exceed $5000. This could be one of the reasons that dialysis patients stop working, either immediately or not long after beginning dialysis. Even if I were to consider long term disability at 60% of my annual base plus bonus compensation, I would still have to deal with over $5000 annually of out of pocket medical expenses, which are far more easily covered on 100% of annual base plus bonus compensation.