Beginning in 2021, people with End-Stage Renal Disease (ESRD) End-Stage Renal Disease (ESRD) is a kidney disease that requires you to be on dialysis or have a kidney transplant. Patients with ESRD may qualify for Medicare coverage regardless of age. can enroll in Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plans. Medicare Advantage Plans must cover the same services as Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. but may have different costs and restrictions. However, Medicare Advantage Plans cannot set cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. for either outpatient dialysis or immunosuppressant drugs higher than would be the beneficiary responsibility under Original Medicare.
If you have ESRD and are interested in enrolling in a Medicare Advantage Plan, it is important to consider provider networks and costs as you evaluate plans.
Provider networks
Each type of Medicare Advantage Plan has different network rules. A network is a group of doctors, hospitals, and medical facilities that work with a plan to provide services. Your costs are typically lowest when you use in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. providers and facilities.
Before enrolling in a Medicare Advantage Plan, make sure your providers, including your dialysis facility, are in network. Ask your current providers which plans they accept. While some plans offer coverage outside their network, costs and restrictions are often higher.
Costs
When you are comparing Medicare Advantage Plans, find out how much you will owe for services you need, such as dialysis and immunosuppressants.
Medicare Advantage Plans have annual maximum out-of-pocket limits on your Part A Part A, also known as hospital insurance, is the part of Medicare that covers most medically necessary hospital inpatient care, skilled nursing facility (SNF) care, home health care, and hospice care. and Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. care ($9,350 in 2025). These limits can help protect you if you have high health care costs. When you are comparing Medicare Advantage Plans, it may be helpful to calculate if you are likely to reach the maximum out-of-pocket limit See Maximum Out-of-Pocket (MOOP). during the year. This is because after you reach the limit, you do not pay anything for in-network covered inpatient or outpatient services for the rest of the year.
Learn more about other factors to consider before you join a Medicare Advantage Plan.
If you are deciding between Original Medicare and Medicare Advantage, use this chart to get started.