Medicare Advantage and Dialysis: What Patients Need to Know

Original Medicare

Original Medicare includes Part A for hospital care and Part B for outpatient services, including dialysis and nephrology care. After the deductible, Part B generally pays 80% of approved costs, leaving the patient responsible for 20% with no annual out-of-pocket limit.

Patients may cover this gap through Medigap or Medicaid. However, Medigap availability varies by state, especially for patients under age 65 who qualify for Medicare because of ESRD. Never assume a patient can purchase Medigap without first confirming eligibility and obtaining a quote.

Medicare Advantage

Medicare Advantage plans are offered by private insurers and replace how Parts A and B benefits are delivered. Most include prescription-drug coverage and may offer additional benefits such as transportation, dental, vision, or meal assistance.

Although many plans have a $0 additional premium, dialysis patients may still owe 20% coinsurance until reaching the plan's annual out-of-pocket maximum. In other words, Medicare Advantage does not necessarily eliminate the 20%—it places a limit on it.

Provider access is another important consideration. An HMO generally requires patients to remain within its network, while a PPO may allow out-of-network care at a higher cost. Saying "we accept Medicare" does not necessarily mean a provider accepts every Medicare Advantage plan.

Before enrolling, patients should confirm that the following participate in the specific plan:

• Their nephrologist
• Their dialysis facility
• Their vascular access surgeon
• Their preferred transplant center

Prescription coverage should also be reviewed carefully. Medicare Advantage plans typically include Part D, but medications must be on the plan's formulary and may require prior authorization.

Ask Before Switching

Before a patient changes coverage, ask:

1. Is the plan Original Medicare or Medicare Advantage?
2. If it is Medicare Advantage, is it an HMO or PPO?
3. Are all current kidney-care providers and facilities in network?
4. Are the patient's medications covered?
5. If the patient later leaves the plan, will Medigap still be available?

A $0 premium does not mean there will be no costs or complications. Helping patients understand the complete plan—not simply the Medicare card—can prevent disruptions in dialysis, specialty care, medications, and transplant access.