Is Medicare Advantage a Plus for People on Dialysis?

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on August 4, 2016.
Is Medicare Advantage a Plus for People on Dialysis?

When Medicare HMO plans came into being in the 1970s, members of the renal community were concerned that insurance companies operating them might put other interests ahead of the needs of the members they were established to serve. Nothing changed when these plans were renamed Medicare + Choice in 1997 and Medicare Advantage (MA) in 2003.1

Are MA plans workable today for those on dialysis? Here are some questions to consider:

  • How are MA plans paid? Medicare pays more to insurance companies that administer MA plans than what it costs traditional Medicare to treat people. This creates a burden to taxpayers—with no improvement in care quality.2

  • Does the MA plan follow CMS rules described in the Medicare Managed Care Manual? 3

  • With an average of three or more chronic health conditions, people with CKD need access to specialists. Do MA plan primary physicians offer timely referral to nephrologists and other specialists for people with CKD?

  • Is the MA plan’s network of providers (dialysis, physicians, hospital, pharmacies, etc.) appropriate and accessible for the patient—and is it stable or could it change? According to the Medicare website, providers can drop out of plans and plans can change networks anytime during a year. This could require a patient to find a new provider.

  • Do the MA plans’ contracted dialysis facilities offer the dialysis options patients want?

  • Do MA plans’ drug formularies include common dialysis and transplant drugs and does the plan account drugs correctly to Part B or Part D? Anecdotally, transplant patients have reported incorrect accounting of immunosuppressants to Part D—causing them to reach the “doughnut hole” sooner, and have to pay full price for these costly drugs.

  • Does the MA plan cover non-emergency transportation to dialysis?

  • Does the MA plan have a case manager who works with all ESRD patients?

  • What are the MA plan’s copays for dialysis? Does the plan have a patient assistance program to waive or help cover dialysis copays and/or medication costs?

  • Are out-of-pockets costs more or less than with traditional Medicare? MA plans are allowed to have an annual maximum out-of-pocket of $6,700 (it can be lower)—and patients can’t have a Medigap plan to help pay. Yet, anyone who is age 65, with or without ESRD, who enrolls in traditional Medicare can buy a Medigap plan within 6 months of enrolling in Part B and have lower out-of-pocket costs than in an MA plan. The following table, revised from the chart on the Medicare website, lists only the states that do require companies to sell Medigap plans to those under 65 with ESRD.

States Requiring Insurance Companies to Offer at Least One Kind of Medigap Policy to People with Medicare and ESRD Who Are Under Age 65

*A Medigap policy is only available to people under age 65 with ESRD.4

If your state isn’t on this list, check with your state insurance department or state health insurance assistance program to see if there may be a company that sells a Medigap policy to an ESRD patient. It’s likely to have a higher premium and may require patients to meet a waiting period for pre-existing conditions. The Patient Protection and Affordable Care Act did not address Medigap plans.

HR5659—Medicare “Choice” or Empty Promise?

On July 7, 2016, Jason Smith (R-MO), John Lewis (D-GA), Gus Bilirakis (R-FL), and Kurt Schrader (D-OR) introduced HR 5659, called Expanding Seniors Receiving Dialysis Choice Act of 20165, in the House of Representatives. Kidney Care Partners6 and its members, including dialysis providers, suppliers, manufacturers, and some nonprofit organizations including patient groups that give KCP higher credibility, are lobbying for this bill.

Dialysis providers want ESRD patients to be allowed to 7“choose” to enroll in MA plans. What is their motivation? Dialysis providers with more MA members may make more money if MA plans don’t bundle drugs and labs like traditional Medicare does. Also, dialysis patients who are members of MA plans may be locked into a certain dialysis corporation’s clinics if that’s the only contracted provider. This could require rural patients to travel long distances or patients to not get the treatment of their choice. Is the “choice” in this bill an empty promise?

On a related note, the Government Accountability Office (GAO) has repeatedly investigated MA plans and found that the government’s risk adjustment of MA payments based on how ill its members are has led to provider “upcoding,” defined as “A fraudulent practice in which provider services are billed for higher CPT procedure codes than were actually performed, resulting in a higher payment by Medicare or 3rd-party payors.” According to the GAO, MA plans that provide unsupported documentation of diagnoses cost the federal government $14.1 billion in 2013 alone.8 As the saying goes, follow the money when looking at the benefits and risks to evaluatie a major proposed change in policy like this bill.

  1. Medicare Advantage,, Accessed August 3, 2016.

  2. Knowledge@Wharton, Why Consumers Don’t Gain Much from Medicare Advantage, June 20, 2014,, Accessed August 3, 2016

  3. Centers for Medicare & Medicaid Services, Medicare Managed Care Manual, 100-16,, Accessed August 3, 2016.

  4. When Can I Buy Medigap?, Accessed August 3, 2016.

  5. Expanding Seniors Receiving Dialysis Choice Act of 2016, HR 5659,, Accessed August 3, 2016.

  6. Kidney Care Partners,, Accessed August 3, 2016.

  7. Upcoding,, Accessed August 3, 2016.

  8. General Accountability Office, Medicare Advantage: Fundamental Improvements Needed in CMS's Effort to Recover Substantial Amounts of Improper Payments, GAO-16-76: Published: Apr 8, 2016. Publicly Released: May 9, 2016,, Accessed August 3, 2016.


  • John Sadler

    Aug 08, 2016 5:18 PM

    You stimulated DaVita to propose a countering paper. I tend to believe traditional Medicare serves people better. I have that. My wife's MA plan, even with Kaiser, is often difficult and more beaurocratic than what I experience. While MA plans offer a few perks to get people enrolled (no Part B premium, several covered drugs) the lack of an open access to providers is the major weakness. Closed networks are less flexible and more rigid. I don't want that for my patients, even though I know MA plans can pay providers more.
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    • Allen Nissenson

      Aug 08, 2016 5:55 PM

      It is unfortunate that the comment is framed as "...DaVita...propose(s) a countering paper...". The CMOs of the dialysis organizations have been meeting for several years to work together to drive what is best for patients, independent of where they dialyze. Opinion papers on fluid management and infection control in the dialysis facility among others have been published, and additional work on home dialysis and depression/pain screening/evaluation/treatment is ongoing. After reading the blog on MA plans I reached out to the CMOs with the following email:

      "The piece attached below made me think that an objective piece on integrated care and its potential to help patients, including ESCOs and SNPs would be useful. The blog paints a very negative picture of MA plans for ESRD patients- and since ESRD patients can’t join these plans it likely refers to SNPs. Correcting the misstatements and showing the benefits to patients of integrated care would be useful to maintain balance for patients and providers. Anyone interested in a white paper/short editorial piece from the CMOs on this topic?"

      I agree with Dr. Sadler that the issue of closed networks can be problematic for patients. However, ESCOs have open networks this is the structure proposed in the Dialysis PATIENT Act recently introduced in the House and Senate. I believe that patient choice is very important, particularly in this vulnerable population, but each patient must weigh whether some decrease of choice is offset but enhanced benefits and better outcomes which have been reported in ESRD SNP programs.

      This topic seems ideal for a thoughtful, objective opinion piece articulating the key perspectives on this approach to kidney patient care and the CMOs have shown that they are more than capable of taking this approach.
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      • Dori Schatell

        Aug 10, 2016 2:17 PM

        Anyone, in any state, who is eligible for Medicare should be able to purchase a Medigap policy. Allen, perhaps this is something Dialysis Patient Citizens could take up as an advocacy measure and a win-win for patients and providers?
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      • Beth Witten

        Aug 09, 2016 12:28 AM

        I agree with Lisa that ESRD patents would be better served if they had access to Medigap plans in those states that don't have regulations requiring insurers selling to those with Medicare due to age to sell the same plans to those under 65 for at least 6 months after getting Part B, like federal law requires for those with Medicare due to age.

        Just to clarify...The concerns I listed in the article came from patients/family members and social workers working in dialysis and transplant settings. I reported issues experienced by patients who were in MA plans when they developed ESRD. There may be other concerns that I didn't list for those who had ESRD and enrolled in MA Special Needs Plans for that population. However, there are so few of those plans in the US that I haven't heard those complaints. Since I wrote this article I learned another concern from a researcher that, although data on patients in Original Medicare is readily available to researchers, he has been unable to obtain similar data on patients enrolled in MA plans. How do we know if those plans are providing high quality care or whether patients have complaints or are satisfied.

        If the CMOs would be interested in perspectives from dialysis and transplant social workers and patients/families related to MA plans patients had when they started treatment, I'd be happy to post a message to the CNSW listserv and on the Home Dialysis Central Facebook page. I could ask Dori Schatell to post a message to other patient message boards she subscribes to as well. The posting could ask for information about experiences with MA plans (positive and negative) to be sent to an email address of whomever you designate. Just let me know. It might be worthwhile for the CMOs to hear a broader perspective.

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  • Lisa Goodwin

    Aug 08, 2016 11:31 AM

    I have been in dialysis and transplant for nearly 20 years and have seen more negative than positive to these plans for renal patients. Many of the dialysis patients are billed for copays per treatment and the transplant patients are on the hook for 20% costs for immunosuppression meds. I work with many patients who have Medicare only and they are billed much less for dialysis costs, but unfortunately have more limited access to transplant due to gaps in coverage. I would like to see more access to Medigap plans rather than the MA plans.
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