People with End Stage Renal Disease (ESRD) are prohibited from enrolling in Medicare Advantage (MA) plans. If, however, they are already enrolled in one and then later develop ESRD, they can stay in their plan; the MA plan cannot drop their coverage.
While these are the general rules, there are a couple of exceptions to this prohibition of joining MA plans, as outlined in CMS’ Medicare Managed Care Manual. One such exception, revised and effective last November (Chapter 2, Section 20.2.2), is that a Medicare beneficiary with ESRD who is already enrolled in an MA plan may join any of the other MA plans within the same parent MA organization during certain enrollment periods. One such period is the Annual Election Period (AEP) which is from October 15 – December 7 starting in 2011.
In the past, CMS limited this exception to apply only to MA plans under the same company, not the same parent organization. For example, a beneficiary with ESRD who was enrolled in a Secure Horizons MA plan could only switch to another Secure Horizons MA plan if one was available. Now, however, a beneficiary meeting 3 conditions (outlined below) can switch to any MA plan offered under the parent organization, United HealthCare Insurance Co. This includes switching from an HMO to a PPO or PFFS plan and vice versa. In many cases, this revision gives ESRD beneficiaries more MA plans to choose from if they want to switch plans.
The 3 conditions determining whether a beneficiary can switch MA plans within the same parent company are:
- The new MA plan must operate in the same state as the beneficiary’s previous MA plan,
- The beneficiary meets all the other requirements for enrollment in that MA plan (i.e. has both Medicare Parts A and B), and
- The effective date of enrollment is prospective from the date of CMS’ memorandum (11.19.10).
For questions about this exception, please contact Jim Canavan at (410) 786-5223 orJames.Canavan@cms.hhs.gov.
For more information on ESRD and Medicare, see our fact sheet PDF: Medicare and People with End Stage Renal Disease (ESRD).