Medicare (Part A and Part B) is a federal health insurance program created in 1965 for people ages 65 and over, regardless of income, medical history, or health status. The program was expanded in 1972 to cover people who have End Stage Renal Disease (ESRD) or a long-term disability.
Medicare Advantage Plans
Medicare Advantage (MA) plans were first signed into law in 1997. These plans are sometimes referred to as “Part C.” Private companies approved by Medicare offer MA plans. If you join an MA plan you are still covered by Medicare. You will see several advertisements and a lot of marketing efforts to try and recruit you into an MA plan.
Part “C” Medicare offers you another way to get your Medicare Part A and Part B benefits. Most MA plans also offer prescription drug coverage under Part D, and they can offer services not covered by Medicare.
Those with Medicare due to a diagnosis of ESRD will become eligible to enroll in MA plans beginning January 1, 2021. Congress had previously excluded people with ESRD because of concerns about inadequate provider network coverage. Note: If you or your spouse had an MA plan prior to an ESRD diagnosis, you would be eligible.
MA plans are required by law to include all the benefits of Medicare Parts A and B.
Provider Networks
A plan contracts with a list of doctors, hospitals, and other health care providers to provide medical care to its members. This is known as a provider network.
For example, if a person with ESRD needs a surgeon to perform a vascular access repair procedure to receive dialysis, they will have fewer choices under an MA plan than if they had opted for “fee for service” Medicare. This is because the surgeon must be in the plan’s provider network. This can sometimes cause a delay in care or require traveling farther to have the procedure done. This also comes into play when someone requires dialysis because they must go to a center that is in their network. It also affects those who are listed for a kidney transplant.
Since chronic kidney disease (CKD) requires a lifetime of ongoing care, another thing to consider is that a provider can change its network, and you may be required to see a new doctor or be assigned to a new dialysis or transplant facility. This can cause issues with the continuity of care you receive, and you will need to get to know your new team, just as they will have to get to know you. In the kidney world, your team can become like family due to the nature of the frequency of care you get over long periods of time. For me, having spent 12 years on dialysis (from ages 12 to 24), my dialysis healthcare team was like family. In fact, I had more renal care professionals at my wedding than relatives from my own family.
MA Plans are attractive because they can offer additional services like dental, vision, and hearing care. These plans can also offer prescription drug coverage, transportation, and gym memberships. The benefits you receive are determined by the specific MA plan. These plans often require only a copay, and may not require you to have a secondary payer for the 20% that Medicare doesn’t cover. They also have limits on out-of-pocket spending.
Another benefit that an MA plan will offer is care coordination. Once you sign up with a plan, a managed care coordinator will reach out to you. Their goal is to provide education and communicate with physicians, discharge planners, and others to help manage your care. They process referrals and request authorization for services.
Another goal of an MA plan is to capture data related to healthcare utilization to try to keep costs down. This may come into play if two treatment options are available. The treatment that is more cost effective will be the preferred pathway of care, even if your doctor thinks otherwise. And MA plans often reduce the amounts paid to healthcare providers.
MA plans are paid an annual fee for each patient that is on their plan, and they take responsibility for overseeing all care. If you do your own dialysis at home, or are transplanted with no complications that require a hospital visit or an additional surgery, this is the ideal scenario for more profitable care. Your health and well-being will now become the central focus to prevent additional costs of care. You may find that you will be sent home from a hospital stay sooner than what feels comfortable to you.
The Decision Is Yours
The Medicare Advantage open enrollment period is October 15 through December 7 each year. During this time you can switch from one Medicare Advantage plan to a different one, or you can switch from a Medicare Advantage plan back to Original Medicare.
There is no perfect scenario. To make an informed choice it is best to know your options.
Here are some questions you should ask before considering an MA plan:
• Will I be able to see my
current doctors?
• Will I need a referral to
see a specialist?
• What will be my out-of
-pocket costs, deductibles,
and copays?
• Will my hospital, transplant
center, and dialysis facility
be in-network?
• Are routine exams covered?
• What additional benefits
are available?
• How many miles away
from my home is a network
considered as adequate?
• Can I travel? What are the
restrictions?
• What happens if I have to
go to an emergency room
or see a doctor that is not
in-network?
• How robust is the plan’s
network of doctors? How
long will I have to wait for a
referral, or to see an in
network healthcare provider?
• What prescription drugs
are covered, and are my
drugs on the list?
• Does the plan include my
local pharmacy, or will I get
medications through the mail?
• How will the quality of the
MA program be measured?
• How long will it take to
appeal a denial of medical
coverage or route of care?
• If I am not happy with my
MA plan, when can I switch
back to Original Medicare?
Lori Hartwell is the Founder & President of Renal Support Network (RSN) and the host of KidneyTalk™, a radio podcast show. Lori was diagnosed with kidney disease at the age of two. In 1993 she founded RSN to instill “health, happiness and hope” into the lives of those affected by chronic kidney disease. Lori is also the author of the inspirational book Chronically Happy: Joyful Living in Spite of Chronic Illness and is a four-time kidney transplant recipient.
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