ESRD treatments begin in prison
Mary, a fully insured individual, was imprisoned on 4/5/ 00. She began a course of
dialysis at the State's expense in 1/01 while still in prison. She filed for R-HI
and R-SMI in 6/03, upon her release from prison. Her R-HI was awarded as of 6/1/02
(12 months retroactive to the date of filing). Mary elected R-SMI to begin as of the
month of filing (6/03), rather than 12 months retroactive. She thus avoided premium
liability for the time during which she could not take advantage of the Medicare coverage.
If Mary had filed for Medicare when first eligible in 2001, she would have had to
pay SMI premiums when there was no possibility of Medicare's paying for her care.
If she had filed for R-HI but refused R-SMI in 2001, or if she had lost R-SMI by voluntary
disenrollment or for nonpayment of her premiums, she would not have R-SMI upon her
release from prison and would be unable to have R-SMI until 7/1/04 based on a 2004
GEP enrollment (unless she is able to withdraw her R-HI application, as described
in HI 00801.197).
Medicare is secondary payer
Gina is working and covered by her employer’s group health plan when she begins a
regular course of dialysis in 1/01. Gina is eligible for Medicare beginning 4/01,
however after learning that the group health plan will be primary payer of her medical
expenses until 9/30/03, she decides to wait to apply for Medicare. In 11/03, Gina
files a Medicare application and elects to have R-HI and R-SMI coverage begin effective
10/1/03, the first month Medicare is primary payer for her medical expenses.