Policy/Memo 74r3

Number: Policy Memo 74r3
Date Issued: August 19, 1994
Date Revised: October 6, 1997
Policy File Ref: A810
Subject: Medicare

ISSUE:

NYSHIP liability for End Stage Renal Disease (ESRD).

Background:

The Omnibus Budget Reconciliation Act of 1993 changed the primary insurer liability from Medicare to employer plans for a limited period for certain enrollees or their dependents who have ESRD. The Balanced Budget Act of 1997 increased the coordination period for ESRD to 30 months. This change applies to all enrollees with ESRD whose coordination period began on or after March 1, 1996. NYSHIP must provide benefits as the primary insurer for 30 months for ESRD enrollees or their dependents, active or retired, who are not receiving primary coverage from Medicare. NYSHIP must also pay as primary insurer for 30 months, if ESRD-based Medicare entitlement occurs simultaneously with age or disability-based entitlement, or if the age or disability entitlement occurs within the 30 month period.

If the individual is receiving primary benefits from Medicare at the onset of ESRD, Medicare will continue to provide primary benefits.

As was previously the case, Medicare imposes a three month waiting period at the onset of ESRD before Medicare coverage becomes effective for this reason. However, the waiting period is waived if the individual has enrolled in a self-dialysis training program within the first three months or receives a kidney transplant within three months of being hospitalized for the transplant. If there is a waiting period, NYSHIP will provide primary insurer coverage for the waiting period and for the next 30 months.

Example 1: The 50 year old spouse of an active employee begins treatment for ESRD as an outpatient. NYSHIP will provide primary benefits for the three month waiting period and the 30 month period that follows

Example 2: A 64 year old retiree begins treatment for ESRD as an outpatient. NYSHIP will provide primary benefits for the three month waiting period and the 30 month period that follows.

Since Medicare will provide only secondary benefits during the 30 month period in which NYSHIP is required to provide primary benefits, some enrollees may choose not to enroll for Medicare coverage. Although there is no NYSHIP requirement that Medicare enrollment be maintained during this period, the individual must have Medicare in effect at the termination of the 30 months or will lose substantial benefits when NYSHIP assumes secondary insurer liability.

Policy:

Provide primary insurer benefits as required by OBRA '93 and the Balanced Budget Act of 1997.