Table 1.

Definitions of important terms in Medicare financing of kidney transplantationa

EligiblePatient paid into Social Security/Medicare for a required number of work quarters (or is the dependent of someone who has) and eligible based on age (>65 yr), disability, or ESRD
EntitledESRD entitlement begins
    first day of the month in which beneficiary begins dialysis self-care program
    first day of the third full month of dialysis (in-center hemodialysis)
    two months (from first of month) before transplantation (if at a Medicare-approved facility)
EnrolledBeneficiary must file completed application for Part A and/or Part B; Part A no premium, Part B requires a monthly premium ($93.50/mo)
Enrollment can occur
    after Medical Evidence report (form 2728) is filed with CMS
    once transplant surgery takes place; for example, surgery is March 19, 2007; enrollment can occur for 2 mo before March 1 (January 1, 2007); Part A: application must be filed; Part B: must apply and pay premiums for January to March at $93.50/mo
COBFor a patient with private insurance, 30 mo after the Medicare effective date (initiation of dialysis or transplantation), Medicare becomes primary (if patient is eligible, entitled, and enrolled) and private insurer becomes secondary
Medicare coverage remains active for only 36 mo after transplantation unless the patient remains Medicare eligible for other reasons (age, disability); in the case of preemptive transplantation in an otherwise healthy recipient <65 yr of age, Medicare would be primary for only 6 mo
OACThese include but are not limited to
    costs incurred by the transplant center in the identification and evaluation of all potential recipients and LD
    costs incurred in LD nephrectomy (Part A; not including physician/surgeon fees that must be claimed under Part B)
    cost of procuring organs from deceased donors, including fee to organ procurement organization
    costs incurred in the maintenance of waiting list
  • a COB, coordination of benefits; LD, living donor; OAC, organ acquisition costs.