Jack's Blog on Medicare Plan Choices

THE QUESTION IS: Can someone with End-Stage Renal Disease (ESRD) enroll into a Medicare Advantage Plan?

It’s not too far-fetched a question. When I first started in this business, ERSD patients were excluded from Advantage plans., but this exclusion ended in 2021.

The exclusion dated back to the inception of the Medicare Advantage program in the 1980s. The costs of treating ESRD patients was financially challenging for private insurers.

A significant policy change came with the passage of the 21st Century Cures Act in 2016. This act mandated that the exclusion of ESRD patients from Medicare Advantage plans be lifted. As a result, starting January 1, 2021, individuals with ESRD became eligible to enroll in Medicare Advantage plans.

This change was implemented to provide ESRD patients with more choice in their healthcare coverage. It’s important to note that Medicare Advantage plans are required to provide at least the same level of coverage as Original Medicare for all Medicare-covered services, including dialysis and kidney transplants. This ensures that ESRD patients don’t lose access to essential treatments when choosing a Medicare Advantage plan.

Furthermore, Medicare Advantage plans must provide an annual out-of-pocket maximum, which can offer significant financial protection for individuals with high healthcare costs, such as those with ESRD. This feature can help limit the total amount patients spend on healthcare in a given year, potentially reducing their financial burden.

Adding to these benefits, starting in 2025, there will be a $2,000 maximum out-of-pocket limit for prescription drug costs under Medicare Part D. This applies to stand-alone Part D plans and Medicare Advantage plans that include prescription drug coverage. For ESRD patients, who often require multiple medications, this cap could provide substantial financial relief.

Taken together, these features of Medicare Advantage plans – equivalent coverage, out-of-pocket maximums, and the upcoming Part D spending cap – offer patients with ESRD some welcome financial protection and potentially more comprehensive coverage options compared to Original Medicare.

Enrollment: Like most people, ESRD patients can enroll in Medicare Advantage plans during the annual Open Enrollment Period (October 15 – December 7) or during their Initial Enrollment Period when first eligible for Medicare.

What to be careful of: Network Restrictions: Some Medicare Advantage plans may have network restrictions, so it’s important for ESRD patients to ensure their preferred providers and dialysis centers are in-network.

I hope you find this information helpful.

Before choosing an Advantage or Supplement plan, ensure you have a thorough understanding of Medicare itself. When it’s time to explore your options, don’t fall for a sales pitch from a single company or an agent representing only one provider.

At “More Plans More Choices,” I can provide you with side-by-side comparisons from various insurance carriers. More carriers plus more plans equals more choices.

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