Mr. Luigi (born 02/10/45) had a kidney transplant on 08/15/01, which was paid for
by his group health plan (GHP). The GHP is primary payer for the 30-month coordination
period that will end in 01/04. On 07/11/02, Mr. Luigi files for R-HI and R-SMI. He
requests R-HI at the earliest possible date, 08/01, and chooses R-SMI coverage effective
with the month of filing, 07/02.
Since Mr. Luigi established R-HI coverage the month of his kidney transplant, effective
02/04 (the end of the coordination period), R-SMI will pay for Mr. Luigi’s immunosuppressive
drugs. R-SMI will continue to pay for these drugs until Mr. Luigi’s R-HI and R-SMI
is terminated on 08/04 (the 36th month after the month of transplant). Upon reaching age 65 in 02/10, Medicare will
again pay for the immunosuppressive drugs if Mr. Luigi enrolls in SMI at that time.
If Mr. Luigi files for R-HI after 08/02, Medicare will not pay for the drugs. Retroactive
entitlement for R-HI is limited to 12 months. The earliest possible entitlement date
for R-HI based on a filing date after 08/02 is 09/01; therefore he cannot establish R-HI
effective with the month of transplant. Also, if Mr. Luigi enrolls in SMI when he
reaches age 65, Medicare will not cover his immunosuppressive drugs.