Pros and Cons of Medicare Advantage Plans Accepting ESRD Patients
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Currently, you won’t be able to join a Medicare Advantage plan if you have End-Stage Renal Disease. But we can expect to see significant changes coming within the next year.
The 21st Century Cures Act allows those with End-Stage Renal Disease to enroll in Advantage policies. Before, these beneficiaries could only get an Advantage policy under minimal conditions. Pros and cons can accompany new changes.
Let’s look at the good, the bad, and everything in-between.
Pros of ESRD Patients Gaining Access to Medicare Advantage Plans
Experts in the dialysis world can see the perks of the new Act. Advantage plans offer extra benefits that Medicare doesn’t provide.
Most Advantage plans provide an array of services. Case-management can be incredibly beneficial for those who suffer from ESRD.
Costs may also be less for patients with End-Stage Renal Disease. But, will these costs be equal across the board for every beneficiary?
What are the pros of Medicare Advantage plans accepting ESRD patients?
According to Nancy L. Scott of the Dialysis Patient Citizens Education Center, the pros are easy to find. Nancy says:
“This is great for dialysis patients as Advantage plans often include benefits that are not offered in traditional Medicare, including case-management services that help to assess patients’ needs, set health goals, and provide ongoing support to patients. The Advantage program also limits a patient’s out of- pocket costs to $6,700 per year, while Medicare beneficiaries with ESRD can face cost-sharing of $15,000 per year or more.”
Cons of ESRD Patients Gaining Access to Medicare Advantage Plans
Many people worry about inflation. End-Stage Renal Disease patients need complex care, and this means costly treatments.
People are also fearful of a reduction in health care benefits.
What are the cons of Medicare Advantage plans accepting ESRD patients?
According to the Better Medicare Alliance, “ESRD patients have complex and costly needs, and Medicare Advantage is well-suited to provide high-value care to this population, because of the coverage and care it offers to chronically ill beneficiaries. However, as these findings suggest, Medicare Advantage plans in areas with the most ESRD patients would likely be underpaid in the current payment system. Without adequate payment, Medicare Advantage plans may be forced to raise consumer costs, reduce supplemental benefits, or limit service areas—not just for ESRD patients, but for all enrollees.”
Will Maximum Out-Of-Pocket Costs Could Be Affected?
Medicare Advantage plans don’t generally consider patients on ESRD as profitable. Health care expenses related to ESRD can be extremely high. End-Stage Renal Disease patients need costly care. The price of care can increase other patients’ costs.
All Advantage recipients may see an increase in Maximum out-of-pocket limits.
Do you feel this will impact MOOP costs?
According to Micael Brady of Modern Healthcare, “End-stage renal disease patients aren’t usually profitable for Advantage plans because they pay higher rates for dialysis than original, fee-for-service Medicare. Advantage plans also have caps on out-of-pocket contributions that increase insurers’ responsibility for the cost of dialysis and related treatments.”
What About Special Needs Plans?
At this point, there’s a lot left up in the air. We don’t know whether access will eradicate or increase the need for Special Needs Plans.
What will happen to the Special Needs Plans that currently accept ESRD patients?
“It’s hard to predict the future on this. It will depend a lot on how payers respond with their Special Needs Plan designs. If plans can find benefit structures that provide value to members while saving money, it’s like that SNP plans will continue to thrive. Also, as ESRD patients come into Advantage plans, it may drive greater patient volume in SNP plans as well, even creating demand for new SNP plans in markets where they don’t currently exist.”
Will Medigap Have Better Coverage with Fewer Costs?
“Medicare recipients with ESRD have full coverage but still can face significant out-of-pocket costs for such things as prescription drug co-payments, annual deductibles, and cost-sharing for dialysis visits and hospital care. Some ESRD patients may buy supplemental health care coverage, such as Medigap, to help cover some of these costs.”
As 2021 gets closer, we’re bound to see an increase in available information. Costs and benefit availability are of utmost importance to everyone. ESRD patients may gain a wider variety of services. But, it may cost all Medicare Advantage recipients.