Medicare Options for Dialysis Patients
You may be familiar with Original Medicare (Medicare Part A and Part B), but did you know Medicare-eligible and Medicare-enrolled end stage kidney disease (ESKD) patients can choose Medicare Advantage (Medicare Part C) plans?*
Read on to learn more about your Medicare options. And remember, it’s your decision to enroll in different coverage and you don’t have to change your insurance.
Don’t know what type of coverage you have OR want to learn about other common types of health insurance? Click here.
*21st Century Cures Act, passed by Congress in 2016
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Understanding Your Medicare Options
There are two main ways people with ESKD can get Medicare coverage: Original Medicare and Medicare Advantage.
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 (prescription drug coverage). Medicare Advantage plans cover the same services as Original Medicare and often offer extra benefits like vision, dental and hearing coverage. Other services could include transportation (like to your dialysis center), meal delivery service, and over-the-counter drugs. These plans include an annual out-of-pocket maximum (so you know the maximum amount you could 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. If you have other/secondary health insurance, you may be able to keep that coverage and use it with a Medicare Advantage plan. For example, you can usually keep Medicaid or commercial insurance, like an employer group health plan. However, Medigap policies can't work with Medicare Advantage plans. If you have a Medigap policy and join a Medicare Advantage plan, you may want to drop your Medigap policy, as your Medigap policy can't be used to pay your Medicare Advantage premium, deductible, or copayments.
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 (prescription drug coverage). Medicare Advantage plans cover the same services as Original Medicare and often offer extra benefits like vision, dental and hearing coverage. Other services could include transportation (like to your dialysis center), meal delivery service, and over-the-counter drugs. These plans include an annual out-of-pocket maximum (so you know the maximum amount you could 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. If you have other/secondary health insurance, you may be able to keep that coverage and use it with a Medicare Advantage plan. For example, you can usually keep Medicaid or commercial insurance, like an employer group health plan. However, Medigap policies can't work with Medicare Advantage plans. If you have a Medigap policy and join a Medicare Advantage plan, you may want to drop your Medigap policy, as your Medigap policy can't be used to pay your Medicare Advantage premium, deductible, or copayments.
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 a national health insurance program administered by the U.S. federal government for people age 65 or older or under 65 with certain disabilities. It’s also for people diagnosed with ESKD. Medicare covers hospital services (Part A) and outpatient services (Part B). People covered by Original Medicare can see any provider who accepts Original Medicare and is accepting new patients. No referral is needed.
Medicare Part A
Medicare Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most Original Medicare recipients don’t pay a monthly premium for Part A. However, if you don't qualify for premium-free Part A, you can buy Part A for up to $499 each month in 20221.
Medicare Part B
Medicare Part B covers outpatient care, medical supplies, most doctors' services and some preventive services. It also covers transplant and immunosuppressive drugs for 36 months after transplant. The standard 2022 Part B premium is $170.102 but could be higher depending on your income. In addition to monthly premium/s, Original Medicare requires you meet a deductible before paying for part of covered services and supplies. You will also be responsible for copayments and coinsurance (the part you pay after meeting the deductible—usually 20%), and there is no cap or out-of-pocket maximum on the amount you could pay in the plan year.
1 You can find additional detail at https://www.medicare.gov/your-medicare-costs/part-a-costs
2 You can find additional detail at https://www.medicare.gov/your-medicare-costs/part-b-costs
Additional Coverage
Some people covered by Original Medicare purchase additional coverage for prescription drugs and out-of-pocket costs. Medicare Part D adds prescription drug coverage and Medicare Supplement Insurance (Medigap) fills "gaps" to help 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. Medicaid is an income-based joint federal and state program that covers services from in-state providers who accept Medicaid, as well some (or all) dental, transportation and prescription costs. To be eligible for Medicaid, you must meet your state’s requirements. Not all dialysis patients with Medicare qualify for Medicaid.
Original Medicare is a national health insurance program administered by the U.S. federal government for people age 65 or older or under 65 with certain disabilities. It’s also for people diagnosed with ESKD. Medicare covers hospital services (Part A) and outpatient services (Part B). People covered by Original Medicare can see any provider who accepts Original Medicare and is accepting new patients. No referral is needed.
Medicare Part A
Medicare Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most Original Medicare recipients don’t pay a monthly premium for Part A. However, if you don't qualify for premium-free Part A, you can buy Part A for up to $499 each month in 20221.
Medicare Part B
Medicare Part B covers outpatient care, medical supplies, most doctors' services and some preventive services. It also covers transplant and immunosuppressive drugs for 36 months after transplant. The standard 2022 Part B premium is $170.102 but could be higher depending on your income. In addition to monthly premium/s, Original Medicare requires you meet a deductible before paying for part of covered services and supplies. You will also be responsible for copayments and coinsurance (the part you pay after meeting the deductible—usually 20%), and there is no cap or out-of-pocket maximum on the amount you could pay in the plan year.
1 You can find additional detail at https://www.medicare.gov/your-medicare-costs/part-a-costs
2 You can find additional detail at https://www.medicare.gov/your-medicare-costs/part-b-costs
Additional Coverage
Some people covered by Original Medicare purchase additional coverage for prescription drugs and out-of-pocket costs. Medicare Part D adds prescription drug coverage and Medicare Supplement Insurance (Medigap) fills "gaps" to help 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. Medicaid is an income-based joint federal and state program that covers services from in-state providers who accept Medicaid, as well some (or all) dental, transportation and prescription costs. To be eligible for Medicaid, you must meet your state’s requirements. Not all dialysis patients with Medicare qualify for Medicaid.
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 (prescription drug coverage). Medicare Advantage plans cover the same services as Original Medicare and often offer extra benefits like vision, dental and hearing coverage. Other services could include transportation (like to your dialysis center), meal delivery service, and over-the-counter drugs. These plans include an annual out-of-pocket maximum (so you know the maximum amount you could 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. If you have other/secondary health insurance, you may be able to keep that coverage and use it with a Medicare Advantage plan. For example, you can usually keep Medicaid or commercial insurance, like an employer group health plan. However, Medigap policies can't work with Medicare Advantage plans. If you have a Medigap policy and join a Medicare Advantage plan, you may want to drop your Medigap policy, as your Medigap policy can't be used to pay your Medicare Advantage premium, deductible, or copayments.
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 a national health insurance program administered by the U.S. federal government for people age 65 or older or under 65 with certain disabilities. It’s also for people diagnosed with ESKD. Medicare covers hospital services (Part A) and outpatient services (Part B). People covered by Original Medicare can see any provider who accepts Original Medicare and is accepting new patients. No referral is needed.
Medicare Part A
Medicare Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most Original Medicare recipients don’t pay a monthly premium for Part A. However, if you don't qualify for premium-free Part A, you can buy Part A for up to $499 each month in 20221.
Medicare Part B
Medicare Part B covers outpatient care, medical supplies, most doctors' services and some preventive services. It also covers transplant and immunosuppressive drugs for 36 months after transplant. The standard 2022 Part B premium is $170.102 but could be higher depending on your income. In addition to monthly premium/s, Original Medicare requires you meet a deductible before paying for part of covered services and supplies. You will also be responsible for copayments and coinsurance (the part you pay after meeting the deductible—usually 20%), and there is no cap or out-of-pocket maximum on the amount you could pay in the plan year.
1 You can find additional detail at https://www.medicare.gov/your-medicare-costs/part-a-costs
2 You can find additional detail at https://www.medicare.gov/your-medicare-costs/part-b-costs
Additional Coverage
Some people covered by Original Medicare purchase additional coverage for prescription drugs and out-of-pocket costs. Medicare Part D adds prescription drug coverage and Medicare Supplement Insurance (Medigap) fills "gaps" to help 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. Medicaid is an income-based joint federal and state program that covers services from in-state providers who accept Medicaid, as well some (or all) dental, transportation and prescription costs. To be eligible for Medicaid, you must meet your state’s requirements. Not all dialysis patients with Medicare qualify for Medicaid.
Comparing Original Medicare and Medicare Advantage
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 $7,550 or less (for 2021) 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.
Tools & Resources
Several resources are available to help you understand your insurance options and enroll in a plan. Medicare and eHealth are two key resources for help understanding your plan options and getting enrolled.Frequently Asked Questions
Download and print this frequently-asked-questions sheet. You may want to keep it handy when you talk with an educator.
Additional Tools & Resources
Several resources are available to help you understand your insurance options and enroll in a plan. You can also visit the Tools & Resources page for more.
Disclaimers: This resource is intended to provide DaVita patients with information about some of the available third party resources for comparing and enrolling in Medicare Advantage plans. Links to third party websites are provided for informational purposes only and are not a substitute for professional advice. Third party websites are governed by the third party’s privacy policy and terms of use, not DaVita’s. DaVita does not endorse or recommend any specific insurance agent, broker, agency, or plan and is not affiliated with or compensated by insurance agents, brokers, or agencies. If you choose to work with a health insurance agent, broker, or agency, please keep in mind they are not affiliated with Medicare and may earn compensation if you enroll in a plan.
eHealthMedicare.com is a non-government website operated by eHealthInsurance Services, Inc., a licensed health insurance agency that sells Medicare products and does business as eHealth. In New York and Oklahoma, eHealth does business as eHealthInsurance Agency. eHealthMedicare.com and eHealth are not affiliated or connected with Medicare or any other government program or agency. DaVita and eHealth are independent entities and not affiliated.
NOTICE
eHealthMedicare.com is a non-government website operated by eHealthInsurance Services, Inc., a licensed health insurance agency that sells Medicare products and does business as eHealth or eHealthInsurance Agency. eHealth is not affiliated or connected with Medicare or any other government program or agency. DaVita and eHealth are independent entities and are not affiliated. DaVita does not endorse or recommend any specific health insurance agencies and is not affiliated with or compensated by insurance agencies.