And since 2021, guaranteed issue rights are extended to people with End-Stage Renal Disease (ESRD) who wish to join a Medicare Advantage plan. (However, Medicare Advantage Special Needs Plans for dual-eligible people (D-SNPs) may still be allowed to exclude people with ESRD).
The Exception to Guaranteed Issue Rights: Medicare Advantage Special Needs Plans (SNPs)
If you apply for a Medicare Advantage Special Needs Plan (SNP), you must meet the "need" addressed by the plan (specific chronic condition(s) or financial need or residence in a long-term care facility). For example, if you join a SNP designed for people with Diabetes - you must be diabetic. If you are currently enrolled in a Medicare Advantage Special Needs Plan and you no longer meet the "need" requirement, you will be granted a Special Enrollment Period (SEP) to enroll in a different Medicare Advantage plan.
More about the exception to Dual- Eligible Medicare Advantage plan Special Needs Plan (D-SNP) guaranteed issue rights
As noted above, some Medicare Advantage SNPS are designed to work with the state Medicaid program and provide benefits for Dual-Eligible Medicaid/Medicare beneficiaries (D-SNPs) and these D-SNPs can deny enrollment to anyone suffering from ESRD - even though, since 2021, a person can join any Medicare Advantage plan even though they have ESRD.
As the Centers for Medicare and Medicaid noted in the regulations dealing with ESRD 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." (https://www.govinfo.gov/content/pkg/FR-2020-06-02/pdf/2020-11342.pdf) Bottom Line: To be eligible for enrollment in a:
(1) Stand-alone Medicare Part D prescription drug plan (PDP), you must
- be eligible for Medicare Part A and/or Medicare Part B and
- live in the Medicare plan's service area (state or multi-state CMS region).
- be enrolled in both Medicare Part A and Medicare Part B and
- live in the Medicare plan's service area (county or ZIP Code area)
(3) Medicare Advantage Special Needs Plan (SNP), you
Related Question: Can a
Medicare Advantage plan deny me coverage because of my health or pre-existing
conditions?
- must be enrolled in both Medicare Part A and Medicare Part B,
- must live in the Medicare plan's service area (county or ZIP Code area), and
- must meet the special needs requirement (for example, you have a specific chronic condition or financial need).
If you no longer meet the SNP requirement at any time, you will be asked to leave the plan, and will be provided a Special Enrollment Period to enroll in a different Medicare Advantage or Medicare Part D plan.
- cannot suffer from kidney failure or End-Stage Renal Disease (or ESRD) if you wish to join some D-SNPs (Dual Medicare/Medicaid Special Needs Plans) - this will depend on the state where you live.
No – with a few exceptions. In general, Medicare Advantage plans no longer ask any health-related questions.In order to join a Medicare Advantage plan, a Medicare beneficiary must only reside in the Medicare Advantage plan’s service area (county or ZIP code) and have both Medicare Part A and Part B coverage. The exceptions:Medicare Advantage Special Needs Plans are designed for people with a specific chronic illness (C-SNPs). C-SNPs can ensure that plan members suffer from the specific chronic condition for which the plan is designed (such as, diabetes, chronic heart failure, kidney failure or End-Stage Renal Disease (ESRD), HIV/AIDS, or dementia).
Historical note about ESRD and Medicare Advantage plan coverage:
From 2006 to 2020, a Medicare beneficiary was not allowed to enroll in a Medicare Advantage plan (MA or MAPD) if they suffered from kidney failure or End-Stage Renal Disease (or ESRD) - that ESRD rule was changed in 2021. As was true before 2021, if you are already a member of a Medicare Advantage plan and then suffer End-Stage Renal Disease (ESRD), your Medicare Advantage plan cannot end your plan coverage based on this medical condition.