How do Medicare and Medicare Advantage plans work together?
Medicare Advantage plans work with Medicare to provide coverage for healthcare benefits to beneficiaries. They must follow rules and standards set by Medicare. The federal government pays Medicare Advantage plans to provide all Medicare-covered benefits. If there is a difference between the amount a Medicare Advantage plan is paid by Medicare and the plan’s actual cost to provide benefits to beneficiaries, the plan must use any savings to provide additional benefits or reduce beneficiary cost-sharing. This is how some Medicare Advantage plans provide coverage for benefits such as routine vision and routine dental service, which are not covered by Medicare.
Medicare issues quality ratings for the plans administered by Medicare Advantage organizations. Medicare surveys Medicare Advantage plan beneficiaries to measure the overall quality of plans, including quality of care, beneficiaries’ ability to access care, plan responsiveness and beneficiary satisfaction. Individual Medicare Advantage plans are rated on a scale of one to five stars, with five stars being the highest score. Ratings are posted on Medicare’s website.
Can I enroll in a Medicare Advantage plan if I have ESRD?
ESRD is a chronic condition resulting from temporary or permanent damage to the kidneys. This damage results in loss of kidney function that can eventually lead to renal failure.
People with ESRD are eligible for Medicare. However, under federal law, a Medicare Advantage plan cannot accept anyone who has ESRD unless the individual:
- Can submit documentation that he or she is the recipient of a successful kidney transplant and no longer requires dialysis
- Began dialysis treatment for ESRD but recovered natural kidney function and no longer requires a regular course of dialysis to live
- Developed ESRD while a member of a health plan offered by a Medicare Advantage organization
- Developed ESRD after he or she signed the enrollment form but before the effective date of coverage
- Is currently a member of a commercial health plan offered by the Medicare Advantage organization and wants to switch to another Medicare Advantage plan
A person with ESRD who was a member of a health plan that is no longer offered in the area in which he or she lives can make one election to enroll in a new Medicare Advantage plan. A person who develops ESRD while enrolled in a Medicare Advantage plan may continue to be enrolled in that plan.