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People with ESRD can enroll in a Medicare Advantage Plan

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.

Understanding Your Medicare Options

There are two main ways people with ESRD can get Medicare coverage: Original Medicare and Medicare Advantage.

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—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

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.

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 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.

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.

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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.

Frequently Asked Questions

Should I switch to Medicare Advantage?

You don’t have to change your insurance. The decision to enroll in a different health insurance plan is always yours and you should enroll in the health insurance plan you feel is best for you based on your individual situation and health care needs. If you’d like help understanding your insurance options, use one of the Insurance Support resources below.

How can I learn more about my Medicare options?

At Medicare.gov, the Medicare Plan Finder can help you compare pricing and benefits between Original Medicare, Medicare Advantage and other types of plans. It also can help you check if your doctors, dialysis facility and current or potential transplant center are in-network with Medicare Advantage plans you are considering. Plans for the next calendar year will be available to view in the fall of the year before. Learn more about how the new Medicare Plan Finder works with this video.

For help understanding your options, see the Insurance Support section below.

If I enroll in Medicare Advantage, can I keep my Medigap plan?

Medigap plans can’t be used to pay your Medicare Advantage plan premiums, copayments or deductibles. Therefore, the Centers for Medicare & Medicaid Services suggests those who join a Medicare Advantage plan consider dropping their Medigap plan.

If you join a Medicare Advantage plan for the first time and aren’t happy with it, you can buy a Medigap plan if you return to Original Medicare within 12 months. Note: If you had a Medigap plan before your Medicare Advantage plan, you may be able to get the same Medigap plan back if the insurance company still offers it. If it isn’t available, you can buy another Medigap plan. However, the Medigap plan can no longer include prescription drug coverage—even if you had it before—but you may be able to join a Medicare Part D plan for prescription drug coverage.

Before you drop your Medigap plan, consider visiting Medicare.gov or contacting us (see the Insurance Support section below) for more information.

When can I enroll in a Medicare Advantage plan?

Each year, Medicare holds an open enrollment period for Medicare Advantage and Medicare prescription drug coverage from October 15 to December 7 for the upcoming calendar year. If you already have Medicare, you can change your coverage from Original Medicare to Medicare Advantage, or from Medicare Advantage to Original Medicare.

If you’re enrolled in a Medicare Advantage plan, you can return to Original Medicare during the Medicare Advantage open enrollment period from January 1 to March 31. You can also switch from one Medicare Advantage plan to another. Your new coverage starts the month after you submit your application.

Some individuals can make their coverage decision outside of the open enrollment periods, including those who are first applying for Medicare.

For more information on signing up for Medicare, check out the CMS “Medicare and You” handbook.

Insurance Support

Need help understanding plan options and coverage differences? We’re here for you.
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.

Additional resources for information and help enrolling in Medicare Advantage:

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.