Starting in 2021, Medicare Advantage plans will no longer have any health-related questions*. So even if you are a Medicare beneficiary suffering from End-Stage
Renal Disease (ESRD), you can join - and keep a Medicare Advantage plan.
(* The exception to this rule is Medicare Advantage Special Needs Plans
(SNPs) designed only for members with a special need or condition or chronic illness.)
In order to join a Medicare Advantage plan, a Medicare beneficiary must (1) reside within the Medicare Advantage plan’s service area (county or ZIP Code area) and (2) have both Medicare Part A and Part B coverage.
This new ESRD rule also applies to employer/union Medicare plans (EGHP); but, depending on your state, may not include Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) and Medicare-Medicaid Plans (MMPs). You can click here for more details
about the changes of Medicare Advantage plan enrollment and End-Stage Renal Disease (ESRD).
As noted above, an exception to the no-health-related questions is that Medicare Advantage Special Needs Plans
(SNPs) require that plan members meet the specific “need” or physical condition that is the focus of the plan (such as being eligible for Medicaid (D-SNP) or suffering from a specific chronic condition (C-SNP) or residing in a long-term care facility (I-SNP)). For example, your Medicare Advantage C-SNP can ask if you are Diabetic if the focus of the C-SNP is Diabetes.Medicare Advantage History: Prior to the 2021 plan year
Before the 2021 plan year, Medicare stated, [i]f you have ESRD, you'll usually get your health care through Original Medicare. You can only join a Medicare Advantage Plan in certain situations, like these:
- You're already in a Medicare Advantage Plan when you develop ESRD. You may be able to stay in your plan or join another plan offered by the same company.
- You’re already getting your health benefits (for example,
through an employer health plan) through the same organization that
offers the Medicare Advantage Plan.
- You had ESRD, but have had a successful kidney transplant,
and you still qualify for Medicare benefits (based on your age or a
disability). You can stay in Original Medicare, or join a Medicare Advantage Plan.
- You may be able to join a
Medicare Special Needs Plan (SNP)
for people with ESRD if one is available in your area.
You have a one-time right to join another plan if both of these are true:
- You have ESRD and are in a Medicare Advantage Plan
- The plan leaves Medicare or no longer provides coverage in your area
You don't have to use your one-time right to join a new plan immediately.
If you go directly to Original Medicare after your plan leaves or
stops providing coverage, you'll still have a one-time right to join a
Medicare Advantage Plan later.
original Medicare source (no longer online 10/05/2020):