Medicare Advantage for ESRD?

[Shaks24]

There is a bipartisan bill ( http://www.nephrologynews.com/house-passes-medicare-advantage-bill-esrd-patients/ ) that passed in the House of Representatives this year that would open up Medicare Advantage plans to those with ESRD facing dialysis and or transplantation. If approved by the Senate and signed by the president this would become a new reality. Currently Medicare Advantage plans are only available to us if you are grand fathered in and under other very limited circumstances. I am wondering if any of our members undergoing dialysis are covered by a Medicare Advantage plan. If so, how has it worked out as to quality of care, choice and costs. Original medicare with a gap policy plus a prescription plan works very well but is getting very expensive as premiums go up each year. Specially when you are under 65 and they sock it to you on the gap policy when you first enrolled.

[Rerun]

That would be good.

[tigtink]

I can't speak for dialysis patients but I can tell you that all three of my transplant centers warned me NOT to switch from traditional Medicare with a Medigap plan to a Medicare Advantage plan. Their experience with these plans has not been good. The monthly premiums are much lower but the copays are much higher if you have ESRD, and even worse these advantage plans work like HMOs and require networks and can deny services that are mandated to be covered under traditional Medicare.

Blue Cross of MI recently increased the premium on my Medigap supplement from $122 a month to $314 a month starting in January. Fortunately MI offers a $125 per month subsidy for my plan for low income disabled people under Medicare. That's still an increase for me, but from everything I understand I risk being removed from the transplant list if I switch to an Advantage plan.

University of MI transplant center is so worried that their transplant candidates will drop the supplement plan because of the rate increases that they sent out a strongly worded letter a couple of months ago warning that switching could make us ineligible for the transplant list. Yesterday I got a follow up call from the financial coordinator to make sure I was aware of the changes and am not planning to switch. Apparently they are calling everyone on the list. They are concerned the lack of adequate coverage and high copayments will lead to noncompliance after the transplant and graft failures.

As I understand it, the Ryan plan is to make traditional Medicare with a supplement too costly in order to force more people to go on the advantage plans. Blue Cross has called me twice and sent multiple letters trying to get me to switch. Even if the government provides premium subsidies for advantage plans, unless they do away with all the copayments and mandate coverage of services, anyone with serious health issues will risk bankruptcy or denial of services like transplant if traditional Medicare is phased out. My guess is that dialysis patients will also face higher costs and less covered services under Advantage plans, but I don't know that for certain. Make sure you read the fine print before signing up!

[Shaks24]

Thank you tigtink. That is very sound advice! My gap policy started at about 280 3 years ago. January 2017 it will be a bit over 400. That makes searching for a less costly alternative tempting but like you said, one has to pay very close attention to the details of an Advantage plan if they even pass the legislation. My hope is that if they do pass this bill they will create some plans aimed at the ESRD community with comprehensive benefits at a lower cost. One can dream! Still I would only proceed to change after very complete due diligence and maybe even a consultation at my local SHIP.

[kickingandscreaming]

I have a Medicare Advantage plan, but I was grand fathered in because I had the plan for several years before I hit end stage.  I live in a big medical area, so the plan covers all the doctors I use anyway.  So far I have had decent luck with it, but this is just my first year on D.  I just learned that they (not clear whether it's Medicare or the insurer) will no longer cover the only binder ($$$$$) that works for me come 2017.  Otherwise, it has been good.  I am not on nor plan to be on a transplant list, so I can't comment on that.

[Shaks24]

That is very interesting kickingandscreaming. If I am not prying too much can you comment on the approximate monthly costs? Between original medicare, my gap policy and prescription policy I will be paying about 605 a month in 2017. Besides premiums in 3 years I have paid virtually nothing else except small co pays on a couple of my meds.

[tigtink]

Here is a paragraph from the U of MI letter:

"Our experience has shown, for people with complex medical conditions such as organ transplant, individual Medicare Advantage/HMO/PPO (all-in-one) options may NOT be your best choice. Often, plans with lower monthly premiums actually result in paying higher out-of-pocket expenses, than you would if you had traditional Medicare, a supplemental plan and a separate Part D policy."

This is consistent with what all three financial coordinators have told me. So if you are thinking about a transplant, always check with the transplant center before switching policies.  Even the local SHIP counselors may not have experience with transplant patients.

Also, if you are multi-listing networks for these advantage plans may prevent you from listing out of state.

[nursey66]

Trump already has his people working on cutting and major revamping of Medicare, He will have it so that the cost will bankrupt most of us with ESRD.

[kickingandscreaming]

That is very interesting kickingandscreaming. If I am not prying too much can you comment on the approximate monthly costs?

my
Off the top of my head, I can't tell you what I pay for Medicare as it is withdrawn from my SS.  But  my monthly premium is $154 and then there are copays (they'r not bad) and an annual cap.

[Michael Murphy]

May wife upos retirment was offered the option OF switching to a Medicare Advantageb policy.  I too was offered the same policy.  I took it and joined the most expensive plan.  Recently over 2 weeks I was in one hospital twice,and two other hospitals once each.  Two angioplasties and a 7.5 hour cardiac ablation with the implantation of a defibrillator in my chest.   So far the bill seems to be $0.00.  With the coverage I have and no deductible the 340 dollars a month plus Medicare costs seem to be the way to go for expensive complex procedures.  After checking online I could not find any bill.  I will post the final,tally but looks great so far.

[Simon Dog]

I am retired now,  but the income adder is trailing (I just got a notice that my punishment for paying additional Medicare taxes by working in 2015 is about $55/month).

[Shaks24]

I have not received my yearly letter yet with the new rate for Medicare B but according to my online account its going from 104.9 to 112. Kind of funny how the bigger increases are in the parts handled by the private sector as in the gap policy and the prescription policy. Just thankful to be able to get them.

[Shaks24]

http://www.nephrologynews.com/president-signs-bill-gives-esrd-patients-access-medicare-advantage/?utm_source=newsletter_121516&utm_medium=email&utm_campaign=newsletter&mkt_tok=eyJpIjoiT0dWbU0yVXlNall5WTJReiIsInQiOiJkSnBEQStkXC90ck01d1A3cDFKXC9vdVpnR2RQdE5OT0Q4cFluVEpNeFU5ZlhDXC8zMm1TcWlPdStTaWVIU0Q1YUx0ZXQ0ZkFPSUYyYkFhTHNMXC9IdUlabTVFbStxYXgrZkpiMGdrMFFwaTNSWEtURkdjM1MweDduXC9MSytpbldHY3RPIn0%3D


Expanding Medicare Advantage to Include End-Stage Renal Disease Beneficiaries (§ 17006)

Starting 2021, all Medicare beneficiaries suffering from ESRD will have the option to enroll in a Medicare Advantage plan. Coverage for kidney transplants will be carved out of the Medicare Advantage plan and reimbursed under Parts A and B. In light of this change, the secretary of the US Department of Health and Human Services (HHS) must consider (1) incorporating into the Star Rating system a quality measure specific to ESRD coverage and (2) revising the Medicare Advantage risk adjustment model to include additional factors regarding chronic kidney disease.

Providing ESRD patients with expanded access to Medicare Advantage coverage could dramatically reshape treatment of and payment for the treatment of Medicare beneficiaries with chronic kidney disease. The Medicare Payment Advisory Commission endorsed opening Medicare Advantage to ESRD patients in 2000. More recently, the bipartisan Senate Finance Committee’s Chronic Care Working Group promoted this policy in its draft legislation. Prominent patient and industry groups including the America’s Health Insurance Plans and the National Kidney Foundation endorsed this effort to open access to Medicare Advantage to ESRD patients. Other stakeholders expressed concern that risk adjustment payments for ESRD patients may be inadequate to cover the cost of dialysis treatment.

These changes are a number of years away, but in preparation:

    Plans should consider how including the ESRD population in the risk pool will affect rate development and their existing provider agreements.
    Plans should evaluate other key factors that could be incorporated into the risk adjustment model to best represent the risk of covering ESRD beneficiaries.
    Plans should monitor CMS for requests for information, rulemaking and other guidance regarding updates to the Medicare Advantage risk adjustment model.
    Providers should evaluate their current membership in Medicare Advantage plan networks and the capacity and volume assumptions underlying their participation agreements.

[tigtink]

Just an update on this issue: my transplant financial coordinator at University of Wisconsin explained that the issue for transplant patients with Medicare Advantage plans is they often do not cover or severely limit coverage of the 20% Medicare B copayment for the immunosuppressant drugs needed after a transplant. Medigap plans are required to cover the 20% but the Advantage plans are free to deny this coverage, which can mean hundreds of dollars a month in copayments that many will not be able to afford. So all three transplant centers have advised me to keep my supplement plan and not switch to the cheaper Advantage plans.

[solid98]

Speaking as someone who has had to deal (battle) with an Advantage plan to get my 81 yo mother ANY rehabilitation after her fall, F@*$ ADVANTAGE PLANS!

It is just another way private insurance companies can deny you coverage and treatment so their shareholders and CEO's can make as much money as they can.

Anyone who still argues for the capitalist approach to medical care has never had to deal with our "superior American system".

After I got her moved to a Skilled Nursing Facility, I learned I could revert her back to original Medicare without penalty. It was WAY easier to get her the rehab and therapy
she needed. Well, until day 22 anyway.

The hell of it is, she changed from a supplemental plan to the Advantra on Jan 1 and her fall was late Feb. She would have been so much better off keeping the supplemental plan.

[nursey66]

With Trump running the country you can count on anything good will go away !

[Simon Dog]

I'd be suspicious of any product with a name like "Advantage".  It's like foreign countries - if they have "Democratic" or  "People's"  in the  name, you can be reasonably sure they are oppressive regimes.  If the name contains both, watch out!!   Remember the "German Democratic Republic" or currently the "Democratic People's Republic of North Korea".