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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, can enroll in a Medicare Advantage plan. 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.
There are two main ways people with ESRD can get Medicare coverage: Original Medicare and 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 annual 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.
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.
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 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 annual 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.
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.
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.
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:
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.
Medicare.gov provides official benefit information on Medicare and Medicare Advantage. The Medicare Plan Finder tool shows you the plans available in your area. It also helps you compare plans and check if your doctors, dialysis facility and transplant center are in-network.
Your State Health Insurance Program (SHIP) can provide one-on-one counseling about your insurance options. Find your SHIP at shiptacenter.org or 1-877-839-2675.
Insurance agencies and individual agents can help you learn about different Medicare Advantage plans and submit an enrollment application. Agencies and individual agents may not offer all Medicare Advantage plans available. Find an agency or individual agent online or contact your state department of insurance.
eHealth is an independent health insurance agency that offers plans from many (but not all) insurance companies. eHealth’s licensed insurance agents can help you review your options and enroll in a plan. Additionally, eHealth has tools to make it easier to find Medicare Advantage plans with your health care providers in network. You can visit eHealth's website for more information or call the eHealth helpline for dialysis patients at 1-844-980-2107 (TTY 711) to speak to an agent, available 24/7.
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.
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