Medicare Advantage

Medicare Advantage, Part C of the Medicare Program, is administered by private insurers similar to health maintenance organizations (HMOs). Many of these plans are premium-free and can provide additional benefits not provided by Original Medicare such as dental, hearing and vision coverage. These plans manage the administration of both inpatient and outpatient services.

In 2018, DPC lobbied Congress to change the law to permit ESRD patients the choice to enroll in Medicare Advantage (MA) plans. The 21^st Century Cares Act, which became effective in 2021, permitted dialysis patients – regardless of age – to enroll in MA plans.

Congress had previously enacted many changes to Medicare managed care that made MA plans more attractive relative to fee-for-service Original Medicare, including an out-of-pocket maximum that is lower than the cost sharing most dialysis patients are responsible for in a year. Medicare beneficiaries in MA plans do not need to purchase Medigap insurance, which will be of particular benefit to patients in states that do not mandate Medigap issuance to under-65 Medicare beneficiaries. Premiums for MA plans can be far less expensive than Medigap supplements.

While some MA plans have a reputation for coordinating the care of patients with complex needs, concerns persist regarding these plans’ restrictive provider networks, pre-authorization barriers, and access to care as an increasing number of plans exit the market. Under federal law, Medicare Advantage plans can update plan benefits and provider networks annually, just like HMOs. Many insurers no longer cover the 20% out-of-pocket costs and have narrowed their provider networks limiting access to physicians, specialty care, dialysis centers and hospitals. In rural areas this is a significant problem for ESRD patients, who may be left traveling for hours to reach an in-network provider.

Today about half of ESRD patients have enrolled in MA plans since the program became available to them in 2021. Very little data is available comparing outcomes between MA and Original Medicare, however, a new study found that patients with MA have lower transplant rates than those with traditional Medicare and a Medigap plan (Healio, October 8, 2026).

Under Age 65 Restrictions:

Individuals ages 65 and older with Medicare Advantage coverage that no longer works for their medical and/or financial situation are able to switch back to Original Medicare and purchase Medigap coverage without penalty either during a one-time 12-month “trial right” period starting on the date of their initial enrollment; if their plan consolidates, discontinues or leaves the market; or if they move and a plan is not available in their area. Medicare Advantage enrollees under age 65 cannot use these federal exemptions.  DPC is working with states to offer guaranteed-issue enrollment windows for those under age 65 to switch back to Original Medicare and purchase Medigap coverage without penalty.