Dialysis Information

Prior to 2021, patients with end-stage renal disease were unable to enroll in Medicare Advantage plans unless there was a Medicare Special Needs plan available in their area for ESRD patients. But that is changing for 2021, under the terms of the 21st Century Cares Act. People with ESRD have the option to enroll in Medicare Advantage for 2021, and CMS expects more than 40,000 to do so. This could be particularly advantageous for beneficiaries with ESRD who are under age 65 and living in states that don’t guarantee access to Medigap plans for people under the age of 65. 21st Century Cares Act

What is the 21st Century Cares Act?

The 21st Century Cares Act (Cares Act) – signed by President Barack Obama in December 2016 – impacted several aspects of the U.S. healthcare system, including the creation of Qualified Small Employer Health Reimbursement Arrangements. Among its many provisions, the law made some important changes to Medicare enrollment.

Medicare Advantage open enrollment period

Starting in 2019, the Cares Act created an annual Medicare Advantage open enrollment period – from January through March – when Medicare Advantage enrollees can choose a different Advantage plan or switch to Original Medicare with or without a separate Medicare Part D plan. The Medicare Advantage open enrollment period replaced the Medicare Advantage disenrollment period, which was created by the Affordable Care Act and existed from 2011 to 2018.

Medicare Advantage disenrollment lasted for only the first 45 days of each year, as opposed to the first three months for the Medicare Advantage open enrollment period. Medicare Advantage disenrollment allowed Advantage plan members to switch to Original Medicare and choose a stand-alone Part D plan if they wished, but could not be used to change from one Advantage plan to another. So the new window is longer and more flexible than the old one. But enrollees are limited to a single change during Medicare Advantage open enrollment, as opposed to multiple changes during Medicare’s fall open enrollment.

People with ESRD allowed to enroll in Medicare Advantage as of 2021

The Cares Act also expanded who can enroll in Medicare Advantage. While most Medicare beneficiaries have an array of coverage options, individuals with End Stage Renal Disease (ESRD) – also known as kidney failure – face fewer choices and potentially large out-of-pocket costs due to the expensive nature of kidney dialysis. Americans with ESRD have historically been unable to enroll in Medicare Advantage plans other than the ESRD chronic condition Special Needs Medicare Advantage plans (C-SNPs) available in few areas. (However, people diagnosed with ESRD after enrolling in an Advantage plan are allowed to retain that coverage.)

An ESRD diagnosis triggers Medicare eligibility, regardless of the person’s age. But the only option for most ESRD beneficiaries is Original Medicare, with potentially high out-of-pocket costs (beneficiaries pay an uncapped 20 percent coinsurance for Part B services, including dialysis). Compounding this issue, there is no federally mandated period when people under 65 can buy Medigap plans on a guaranteed issue basis, without medical underwriting. Some states have kept their high-risk pools open to individuals in this situation, and quite a few states have implemented rules to ensure access to Medigap plans for people under age 65. But some of those states still exclude people with ESRD from those protections (click on a state on this map to see how Medigap rules work for people under age 65).

The good news for people with ESRD is the Cares Act changed the law so people with kidney failure will be able to enroll in Medicare Advantage starting in 2021. While Advantage plans can have high out-of-pocket maximums – $6,700 is the federal limit in 2020, with plans averaging around $5,000 – this is better than not having any protection against out-of-pocket costs.