Summary Plan Description

Kidney Dialysis

90% Network and 80% Non-Network
Services and Supplies Must Be Precertified Unless the Patient Is a Medicare-Eligible Retiree

Benefits are provided for kidney dialysis performed in a hospital, an approved kidney dialysis treatment center or in a patient's home when it is repetitive and for chronic, irreversible kidney disease. Benefits may also be provided for the rental or purchase of home kidney dialysis equipment.

If a patient is diagnosed with end-stage renal disease (ESRD), he or she may be eligible for Medicare coverage by nature of the diagnosis. The patient is not required by the plan to apply for and enroll in Medicare Part A and/or Part B if he or she has ESRD. However, enrolling in Medicare when eligible may offer some protection from balance billing by the provider of ESRD services. Balance billing means the difference between the billed amount and the amount allowed by the plan and/or Medicare.

Benefits for outpatient kidney dialysis for treatment of ESRD are as follows:

  • If a patient is not yet eligible to enroll in Medicare, benefits are provided for dialysis as described above.
  • If a patient is enrolled in, or is eligible to enroll in, Medicare, and Medicare becomes or is eligible to become the secondary payer for ESRD services and supplies (regardless of whether the patient is actually enrolled in Medicare), benefits for kidney dialysis are provided at 150 percent of the current Medicare allowed amount.
  • If Medicare becomes primary payer for ESRD services, the plan pays secondary to Medicare and coordinates benefits up to 100 percent of the then current Medicare allowed amount for kidney dialysis.

Notwithstanding the above, the plan may, at its sole discretion, agree to a contractual arrangement for payment with a provider of ESRD services. The contract may allow for a different payment for ESRD services than listed above, but in no circumstances will a contractual arrangement allow for a payment less than the payments listed above.

In order to ensure the correct coordination of claim payments between the plan and Medicare, a participant or dependent is required to provide Carpenters Trusts with the effective date of Medicare coverage.