End Stage Renal Disease (ESRD) is a condition of kidney failure requiring dialysis (a treatment that cleans the blood when the kidneys do not work) and /or kidney transplants. ESRD patients may be eligible for Medicare regardless of their age, employer group size, or employment status (i.e. retired).
If the members Group Health Plan is primary because of disability, age, etc, other than ESRD, then the Group coverage will continue to pay primary during the first 30 (for home dialysis) or 33 (for center dialysis) month coordination period from the 1st date of dialysis. Once the coordination period has been completed, then Medicare becomes primary. If Medicare has been deemed primary because of a disability, age, etc and THEN the member develops ESRD, Medicare will remain primary and the ESRD guidelines will not be applicable. Medicare remains primary in this situation only.
In addition, if a kidney transplant occurs during the coordination period, the Group Health Plan will continue to pay primary until the 30 or 33 months have been completed. Once the coordination period has been completed and Medicare becomes primary and a transplant occurs during this time, Medicare will remain primary for 36 months from the transplant date. If the transplant is a success after the 36 months then the Group Health Plan would then again become primary.
Our system will identify members with ESRD and store their Medicare coverage information. It is the provider’s responsibility to determine who the primary carrier is and track the coordination period.