Can I join a Medicare Advantage plan even though I have End-Stage Renal Disease (ESRD)?

Yes.  If you are Medicare-eligible and suffer from kidney failure or End-Stage Renal Disease (ESRD), you can join a Medicare Advantage plan (MA or MAPD).

In fact, since 2021, enrollment applications for Medicare Advantage plans no longer question whether the applicant suffers from ESRD.

This rule also applies to employer / union Medicare plans (EGHP).  However, depending on the state, the ESRD-rule may not apply to Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) or Medicare-Medicaid Plans (MMPs) -- you can read more below.

As a note, prior to 2021, Medicare beneficiaries with ESRD could not join a Medicare Advantage plan (unless it was a Medicare Advantage Special Needs Plan designed for ESRD or a C-SNP), but people who developed ESRD while enrolled in a Medicare Advantage plan could keep their Medicare Advantage coverage if they were already enrolled before developing kidney failure.  Also, employer / union Medicare Advantage plans (EGWPs) were allowed a waiver for enrollment of plan members with ESRD.

Section 17006(a) of the 21st Century Cures Act (Pub. L. 114-255) amended the Social Security Act allowing all Medicare-eligible individuals with ESRD to enroll in Medicare Advantage plans beginning January 1, 2021.  And on June 2, 2020, the Centers for Medicare and Medicaid Services (CMS) published a final rule updating the federal regulations regarding the enrollment of Medicare beneficiaries with ESRD.

Based on this change, the Centers for Medicare and Medicaid Services (CMS) "estimates that an additional 83,000 people with ESRD will enroll in [Medicare Advantage plans] by 2026, which represents an increase of 63%."

(https://www.ahip.org/medicare-advantage-what-is-changing-for-beneficiaries-with-end-stage-renal-disease-esrd-in-2021/)

In general, public responses to the new law were positive noting that:

• "[A]llowing these [ESRD] beneficiaries to enroll in MA plans will provide care coordination and, thus, improved clinical outcomes for this vulnerable population."
  
  
• "MA beneficiaries have a relatively low rate of switching among plans and tend to stay with the selected plan long term, and this could contribute to better outcomes through longer coordination of care."
  
  
• "[T]his change will provide options for obtaining supplemental benefits and access to health and wellness programs not available in Original Medicare."
  
  
• "MA plans provide a maximum out-of-pocket (MOOP) cost sharing for all enrollees, which makes MA an attractive option for these beneficiaries with high annual medical costs" and "MOOP may significantly decrease patients’ out-of-pocket costs."
  
  
• The MOOP is especially important for those ESRD beneficiaries who are under age 65, and may not be eligible to purchase a Medigap policy to supplement their Original Medicare expenses.
  
  
• "[T]his provision will help improve the lives of, and empower, ESRD beneficiaries consistent with the President’s Executive Order on Advancing American Kidney Health.
  

Question:  Will Employer or Union Medicare Advantage plans allow the enrollment of people with ESRD?

Yes.  In the past Employer/Union Group Health Plans (EGHPs) could allow people to join who suffered from ESRD, but now all Medicare Advantage plans will allow the enrollment of Medicare-eligible people with ESRD.

CMS noted that with "the enactment of the Cures Act, effective plan years on or after January 1, 2021, the prohibition on MA enrollment for ESRD beneficiaries is removed. Therefore, the [employer/union group waiver for enrollment of ESRD members] will no longer be effective and MA plans, including MA EGWPs [employer group waiver plans], must accept enrollments of ESRD beneficiaries. [CMS plans] to update guidance as soon as possible."

Question:  Can Medicare Advantage Special Needs Plans for Dual Eligible Medicare beneficiaries (D-SNPs) exclude people with ESRD?

Yes.  A Medicare Advantage Special Needs plan for Dual-Eligible Medicare/Medicaid beneficiaries (D-SNP) can exclude people who suffer from End-Stage Renal Disease, even though, since 2021, these people are allowed to join any other type of Medicare Advantage plan.

Medicare noted in the comments to the regulations dealing with ESRD and Medicare Advantage plan enrollment: "States already have the ability in their state Medicaid agency contract with each D–SNP to restrict which dually-eligible individuals may enroll in the D–SNP. If the state’s contract with a D–SNP excludes those with ESRD, the D–SNP may retain that exclusion in order to comply with the state contract required under § 422.107."


Question:  Can Medicare-Medicaid Plans (MMPs) exclude people with ESRD?

Yes.  Like D-SNPs, due to the nature of the state / federal contracting, a MMP plan can exclude people who suffer from ESRD.  However, in practice, most states with MMPs accept people who suffer from ESRD.  Only South Carolina and six California counties do not allow Medicare beneficiaries with ESRD to join their MMPs and CMS plans to work with these states to determine whether these exclusions will continue in 2021 or beyond.

Medicare noted in the comments to the new regulations: "We note that currently, most states that are testing a capitated model of integrated care in demonstrations under the Financial Alignment Initiative (FAI) authorized under section 1115A of the Act permit those beneficiaries with ESRD to enroll in MMPs.  Only South Carolina and six counties in California exclude those with ESRD from enrolling in an MMP.  We are consulting with those two states to determine if, starting CY2021, they want to continue that exclusion under the model of integrated care being tested under the FAI demonstration authority. If they decide they do want to include the ESRD population, CMS would work with those states to update the applicable Medicaid MMP rates, as needed." [emphasis added]


Question:  Might Medicare Advantage plan premiums increase overall when people with ESRD are allowed to join Medicare Advantage plans?

Maybe.  Some experts have suggested that a "large influx of [Medicare] beneficiaries with ESRD into the [Medicare Advantage] program could put upward pressure on premiums or lead to reductions in supplemental benefits" unless their were "major policy changes" because beneficiaries with ESRD account for 7% of Medicare spending although the beneficiaries with ESRD "represent less than 1% of the total Medicare population" and, experts estimate "that under current rules, the average [Medicare Advantage] plan has a medical loss ratio of 112% for their [plan] members with ESRD."

CMS acknowledged these concerns when publishing the final regulations noting that most people commenting on the proposed regulations "expressed concern that the ESRD benchmarks are not representative of the costs for ESRD beneficiaries in [Medicare Advantage plans], resulting in underpayment. Many commenters highlighted potential consequences of inadequate rates, including the adoption of discriminatory benefit and network designs to discourage ESRD beneficiaries’ enrollment, inhibited ability to deliver high quality care and services, increased premiums, and reduced benefits. Many commenters encouraged CMS to exercise its authority to adjust the ESRD rates to more accurately reflect costs." 

CMS continued to note that they "appreciate the concerns commenters have raised. [And CMS] will continue to analyze these issues and consider whether, consistent with the statutory requirements for setting ESRD rates in section 1853(a)(1)(H) of the Act, any refinements to the methodology may be warranted in future years."


Sources include: