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People with ESRD can enroll in Medicare Advantage for 2021 coverage
If you or a loved one has end stage renal disease (ESRD), you may be familiar with Original Medicare (Medicare Part A and Part B), but not with Medicare Advantage (Medicare Part C). Because of the 21st Century Cures Act, passed by Congress in 2016, ESRD patients who are eligible for Medicare, or already enrolled in Medicare, will be eligible this fall to enroll in Medicare Advantage for 2021 coverage. This means ESRD patients have expanded Medicare options and important decisions to make about the coverage right for them.
Read on to learn more about your Medicare options. You can also learn about other common types of health insurance here.
Understanding Your Medicare Options
There are two main ways people with ESRD will be able to get Medicare coverage for 2021: Original Medicare and Medicare Advantage.
Medicare Advantage
What is Medicare Advantage?
Original Medicare
What is Original Medicare?
What is Medicare Advantage?
Medicare Advantage plans (Part C) are an “all-in-one” alternative to Original Medicare. The federal government contracts with insurance companies to offer these plans that bundle Medicare Part A, Part B and usually Part D—covering the same services as Original Medicare and often including extra benefits. These plans include an out-of-pocket maximum (so you know the maximum amount you may pay for eligible services in a plan year). They also may require you to see network providers or pay more to go out of network.
To be eligible for Medicare Advantage, you must first enroll (or already be enrolled) in both Medicare Part A and Part B.
Medicare Advantage plans (Part C) are an “all-in-one” alternative to Original Medicare. The federal government contracts with insurance companies to offer these plans that bundle Medicare Part A, Part B and usually Part D—covering the same services as Original Medicare and often including extra benefits. These plans include an out-of-pocket maximum (so you know the maximum amount you may pay for eligible services in a plan year). They also may require you to see network providers or pay more to go out of network.
To be eligible for Medicare Advantage, you must first enroll (or already be enrolled) in both Medicare Part A and Part B.
What is Original Medicare?
Original Medicare is administered by the federal government and available to ESRD patients. It covers hospital services (Part A) and outpatient services (Part B). Individuals covered by Original Medicare can see any provider who accepts Original Medicare and is accepting new patients.
Most individuals covered by Original Medicare pay a Part B monthly premium based on income level, as well as out-of-pocket costs (deductibles, coinsurance and copays) for care received. Individuals typically pay 20 percent of the Medicare-approved amount for most doctor services, outpatient therapy (including dialysis) and durable medical equipment. Original Medicare doesn’t have an annual out-of-pocket maximum, so there is no cap on the amount you may pay in a plan year.
Additional Coverage
Some individuals covered by Original Medicare choose to get additional coverage for prescription drugs and out-of-pocket costs. Medicare Part D adds prescription drug coverage, and Medicare Supplement Insurance (Medigap) fills "gaps," helping to cover out-of-pocket costs not covered by Medicare Part B. Medicare Part D and Medigap plans typically have a monthly premium in addition to the Part B premium.
Original Medicare is administered by the federal government and available to ESRD patients. It covers hospital services (Part A) and outpatient services (Part B). Individuals covered by Original Medicare can see any provider who accepts Original Medicare and is accepting new patients.
Most individuals covered by Original Medicare pay a Part B monthly premium based on income level, as well as out-of-pocket costs (deductibles, coinsurance and copays) for care received. Individuals typically pay 20 percent of the Medicare-approved amount for most doctor services, outpatient therapy (including dialysis) and durable medical equipment. Original Medicare doesn’t have an annual out-of-pocket maximum, so there is no cap on the amount you may pay in a plan year.
Additional Coverage
Some individuals covered by Original Medicare choose to get additional coverage for prescription drugs and out-of-pocket costs. Medicare Part D adds prescription drug coverage, and Medicare Supplement Insurance (Medigap) fills "gaps," helping to cover out-of-pocket costs not covered by Medicare Part B. Medicare Part D and Medigap plans typically have a monthly premium in addition to the Part B premium.
What is Medicare Advantage?
Medicare Advantage plans (Part C) are an “all-in-one” alternative to Original Medicare. The federal government contracts with insurance companies to offer these plans that bundle Medicare Part A, Part B and usually Part D—covering the same services as Original Medicare and often including extra benefits. These plans include an out-of-pocket maximum (so you know the maximum amount you may pay for eligible services in a plan year). They also may require you to see network providers or pay more to go out of network.
To be eligible for Medicare Advantage, you must first enroll (or already be enrolled) in both Medicare Part A and Part B.
What is Original Medicare?
Original Medicare is administered by the federal government and available to ESRD patients. It covers hospital services (Part A) and outpatient services (Part B). Individuals covered by Original Medicare can see any provider who accepts Original Medicare and is accepting new patients.
Most individuals covered by Original Medicare pay a Part B monthly premium based on income level, as well as out-of-pocket costs (deductibles, coinsurance and copays) for care received. Individuals typically pay 20 percent of the Medicare-approved amount for most doctor services, outpatient therapy (including dialysis) and durable medical equipment. Original Medicare doesn’t have an annual out-of-pocket maximum, so there is no cap on the amount you may pay in a plan year.
Additional Coverage
Some individuals covered by Original Medicare choose to get additional coverage for prescription drugs and out-of-pocket costs. Medicare Part D adds prescription drug coverage, and Medicare Supplement Insurance (Medigap) fills "gaps," helping to cover out-of-pocket costs not covered by Medicare Part B. Medicare Part D and Medigap plans typically have a monthly premium in addition to the Part B premium.
Medicare Coverage Considerations
Click on the boxes below to see how Medicare Advantage and Original Medicare differ. As you review your Medicare coverage options, here are some key considerations to keep in mind:
- Do you want to better manage your health care costs?
- Do you want additional benefits, like dental and vision?
- Do you want to see certain providers, like your nephrologist and dialysis center?
- Do you have a Medigap plan you may want to keep?
Extra Benefits
Extra Benefits
Medicare Advantage plans typically offer additional benefits Original Medicare doesn’t, such as vision, dental and hearing coverage. Other covered services could include transportation (such as to your dialysis center), meal delivery service and over-the-counter drugs.
Prescription Drug Coverage
Prescription Drug Coverage
Medicare Advantage plans usually include Medicare Part D prescription drug coverage, so you may not need a separate Medicare Part D plan. Each plan can vary in cost and drugs covered.
Provider Network
Provider Network
With Original Medicare, you can see any provider that accepts Medicare, but Medicare Advantage plans have provider networks. Network providers are contracted with the insurance company to provide services at a certain rate. You'll want to check if your preferred providers are in the plan's network. If you see an out-of-network provider, you may pay more for services.
Monthly Bill
Monthly Bill
Many Medicare Advantage plans have low to no monthly premiums, which vary based on where you live, the plan and benefits offered. If you enroll in a Medicare Advantage plan, you’d still have a Medicare Part B premium, but the plan may pay part or all of that premium.
Out-of-Pocket Costs
Out-of-Pocket Costs
Medicare Advantage plans have out-of-pocket maximums of $6,700 or less (for 2020) for in-network services, but costs for eligible services may differ from Original Medicare. Be sure to check what costs apply to the maximum. Original Medicare doesn’t limit out-of-pocket costs, which can be $7,500+ for dialysis alone.
Coordination of Benefits
Coordination of Benefits
If you get a Medicare Advantage plan, you can't use a Medigap plan to pay your premium, deductible or copays. If you choose to drop your Medigap plan, note that you likely won’t be able to get it back. You can usually keep Medicaid or commercial insurance (an employer plan, for example) as secondary insurance.
Insurance Support
If you have kidney disease but haven’t started dialysis, call the Patient Advocate Helpline: 1-888-405-8915.
DaVita dialysis patients, talk with your social worker, call a DaVita insurance educator (1-833-959-1724) or fill out our Insurance Support Form.
Additional Resources
It’s important to understand all of your coverage options before making any changes. For a list of things to consider when reviewing your options, click here.
Learn more about Medicare Advantage by visiting Medicare.gov or calling 1-800-MEDICARE. You can also contact your local state health insurance assistance program (SHIP), a federally funded state program, for one-on-one counseling and assistance with Medicare. Use the SHIP locator at shiptacenter.org or call 1-877-839-2675.
The following resources may also be helpful: