Get the Medicare Coverage You Need for a Chronic Condition

Kidney failure

• If you have kidney failure — also known as end-stage renal disease (ESRD) — and you need regular dialysis or have had a recent kidney transplant, you may qualify for Medicare before you turn 65. Currently, 17 states won’t guarantee access to Medigap supplemental insurance for people who have kidney failure and are under age 65. If that’s the case for you, consider enrolling in a Medicare Advantage plan. “These plans have an annual out-of-pocket maximum,” says Holly Bode, vice president of government affairs at the American Kidney Fund. “This cap on out-of-pocket expenses is particularly important for patients who don’t have guaranteed access to Medigap.”

• Medicare Advantage plans may offer additional benefits, such as a care coordinator and transportation to and from dialysis appointments. A Medicare Advantage SNP for people with end-stage renal disease may include education, self-training, services and supplies to support dialysis and manage care, transportation, nutritional counseling, and a dedicated kidney care team that works with your primary care doctor and nephrologist to coordinate your care, says Neil Steffens, president of Elevance Health’s Medicare East Region.

• If you’re interested in a Medicare Advantage plan, make sure your nephrologist and dialysis provider are covered. Also, find out which kidney transplant centers are included in the plan’s network.

• Find out how dialysis is covered. Original Medicare covers outpatient dialysis under Part B, which has a 20 percent copayment that can be covered by a Medigap policy or retiree coverage. If you have Medicare Advantage and travel frequently to a second home or to visit family members, find out how dialysis providers would be covered in the other location.

For more information, see Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.

Cancer

• Cancer SNPs are rare, but some standard Medicare Advantage plans offer extra coverage that can help, such as transportation to chemotherapy or radiation therapy appointments. “You’re often asked not to drive to those appointments, so transportation may be an important benefit for people who have cancer,” says Leo.​​ The type of transportation service, number of trips and distance you can travel varies from plan to plan, says Anna Howard of the American Cancer Society’s Cancer Action Network.

• Make sure your oncologist, other doctors and hospitals you want to use are covered by your plan. Having the flexibility to choose your own doctor can be particularly important to consider when deciding between original Medicare and Medicare Advantage. “Cancer is not just one disease, and oncologists may have different subspecialties,” says Howard. “Cancer treatment can vary and can consist of surgery, chemotherapy and/or radiation. Each of these treatments may be handled by different providers.”

• Some academic medical centers that offer advanced treatments may not be included in a Medicare Advantage plan’s network. Check on the hospitals in your area, as well as other hospitals where you may want to go for special treatment. For example, the MD Anderson Cancer Center, which is headquartered in Houston, with hospitals in a few other states and contracted with Blue Cross Blue Shield plans in several states, has working relationships with some other Medicare Advantage plans. They recommend contacting your plan to find out if it will cover services provided by MD Anderson. Original Medicare, on the other hand, covers all hospitals that accept Medicare.

• Find out about any prior authorization requirements. Some Medicare Advantage plans require you to obtain approval before you have surgery or imaging procedures, says Howard.

• Understand coverage for chemotherapy. If you have original Medicare, it’s covered by Part B. You’ll have a 20 percent copayment that can be covered by Medigap, a retiree plan or other supplemental coverage.

• Compare out-of-pocket costs for your prescription drugs under the Part D or Medicare Advantage plans available in your area. Cancer drugs are among the most expensive drugs covered by Part D.

For more information, see Medicare Coverage of Cancer Treatment Services.

Heart failure and cardiovascular disorders

• If you’re considering a Medicare Advantage plan, find out if there are any SNPs in your area. Some of the most common plans focus on cardiovascular disorders and heart failure, or they may help people manage both diabetes and heart conditions. For example, some of Elevance Health’s SNPs that cover diabetes and heart disease have special coverage for medications, blood glucose and insulin management tools, nutrition counseling and fitness programs, says Neil Steffens of Elevance Health. Members receive a personalized care plan from a team that includes a nurse practitioner, primary care physician, nutritionist, registered dietitian and exercise coach. The patient’s primary care doctor works with cardiologists and endocrinologists for heart and diabetes SNPs to coordinate care, he says. Some plans include additional benefits, such as healthy meals and medication management.

• Some standard Medicare Advantage plans offer special benefits for people with heart conditions, such as a blood pressure cuff for members with high blood pressure, healthy eating programs, nutrition counseling and exercise programs. Some plans even help cover the cost of tai chi classes for people with heart conditions, says Melinda Munden, director of the State Health Insurance Assistance Program (SHIP) in North Carolina.

• Find out if your cardiologist, other doctors and hospital are covered by the Medicare Advantage plan you’re considering. If you need complex surgery and want to go to an out-of-network hospital, you may have some coverage but higher copayments if your plan is a preferred provider organization (PPO). Plans that are health maintenance organizations (HMOs) may not offer out-of-network coverage. If you can’t get a certain treatment in-network, some insurers will cover out-of-network services they consider medically necessary. But this authorization can be difficult to get and may take several weeks. Stick with original Medicare if you want the flexibility to choose any doctor or hospital that accepts Medicare.