New research raises questions about access to kidney transplants. Here’s what California patients should know about Medicare Advantage, HMOs and choosing health coverage.
People with kidney failure who had Medicare Advantage were less likely to receive a kidney transplant than patients with traditional Medicare, according to a new study published in the medical journal JAMA.
Even after researchers accounted for several patient and socioeconomic factors, Medicare Advantage patients had a 29% lower rate of receiving a transplant.
They were also less likely to get onto a transplant waiting list.
For someone spending hours each week on dialysis, those findings have significance. A kidney transplant can offer a better quality of life and longer survival than remaining on dialysis.
But the research also raises a difficult question: If Medicare covers kidney transplants, why would patients with different Medicare plans have different outcomes?
The study followed 630,848 Medicare beneficiaries ages 18 to 74 with end-stage kidney disease from 2021 through 2023.
Researchers found that Medicare Advantage patients received 2.51 kidney transplants for every 1,000 months of patient observation, compared with 4.60 among patients with traditional Medicare.
After adjusting for factors including age, socioeconomic status, Medicare-Medicaid eligibility and duration of kidney disease, Medicare Advantage patients had:
- A 29% lower kidney transplant rate.
- A 23% lower rate of being added to a transplant waiting list.
- A 9% lower transplant rate among patients who were already wait-listed or became wait-listed during the study.
These percentages describe differences in rates between groups, not an individual patient’s chances of receiving a transplant.
The findings come as more people with kidney failure are enrolling in Medicare Advantage. After federal rules expanded eligibility in 2021, enrollment among Medicare beneficiaries with end-stage kidney disease rose from 25% in 2020 to 52% in 2023.
The study included Hispanic patients, who represented 19.4% of participants. However, the overall findings do not establish whether Hispanic patients experienced the same differences as the entire study population.
Why getting on the waiting list matters
Getting a kidney transplant involves more than finding a donor.
Patients generally need a referral to a transplant center, medical tests and an evaluation to determine whether surgery is appropriate. Those who qualify may then be placed on a waiting list.
A problem at any of those steps can affect a patient’s path to transplantation.
The researchers found differences not only in the number of transplants performed but also in how often patients reached the waiting list.
Still, the study does not prove that Medicare Advantage caused those differences.
Researchers lacked detailed information about some patients’ medical conditions, transplant eligibility and personal treatment preferences. They also could not determine whether specific insurance restrictions explained the results.
The findings identify a concern about access, but they do not establish that any particular insurance company denied or delayed a transplant.
What if your Medicare plan is an HMO?
Many Medicare Advantage plans are HMOs, meaning patients generally receive care through a network of doctors and hospitals approved by their insurance plan.
For someone who needs a kidney transplant, that network can prove important.
Medicare Advantage plans must cover Medicare-covered kidney transplant services. But patients may still need referrals, prior authorization or treatment at a transplant center that participates in their plan.
In other words, having insurance that covers a transplant does not automatically mean every transplant hospital is available to you.
Some Medicare Advantage PPO plans allow more flexibility to receive care outside their networks, although patients may pay more.
The JAMA study did not separately establish whether HMO patients had different transplant outcomes from PPO patients. Researchers also could not examine individual plans’ hospital networks or authorization requirements.
That means patients should check the rules of their own plan rather than assume all Medicare Advantage coverage works the same way.
What California patients should check before changing Medicare plans
Medicare’s annual Open Enrollment period runs from October 15 through December 7. This is when beneficiaries can review their coverage and make changes for the following year.
For someone receiving dialysis, undergoing a transplant evaluation or already on a waiting list, changing insurance deserves extra care.
Before making a decision, patients and families should ask:
- Is my transplant center covered? Confirm that the hospital and transplant specialists accept the exact insurance plan being considered.
- Will I need approval before treatment? Ask about referrals and prior authorization for evaluations, tests, surgery and follow-up visits.
- What happens if I’m already on a waiting list? Check with the transplant team before changing coverage to avoid interruptions in care.
- Will my medications be covered? Review coverage and costs for anti-rejection drugs and other medicines needed after surgery.
- What will I actually pay? Compare premiums, deductibles, copayments and other out-of-pocket costs.
Patients who need help getting to medical appointments should also check transportation benefits. Some Medicare Advantage plans provide transportation assistance, but benefits and restrictions vary. In a seperate article, we looked at how transportation coverage works for medical appointments.
Traditional Medicare generally offers broader provider choice, but patients may face significant out-of-pocket expenses. Supplemental Medigap coverage can help with some costs, although enrollment rights and eligibility restrictions matter.
For more background, see Parriva’s guide to Medicare’s annual enrollment choices.
Where California patients can get free help
California’s Health Insurance Counseling and Advocacy Program (HICAP) offers free, confidential Medicare counseling.
Patients and families can call 800-434-0222 to get help understanding coverage options, comparing plans and addressing Medicare-related problems.
For Los Angeles residents, the Center for Health Care Rights provides Medicare counseling through HICAP.
Before switching coverage, patients should speak with their transplant team and confirm that their doctors, hospital and necessary medications will remain accessible.
What the findings mean for patients
The JAMA researchers say closer monitoring of transplant access in Medicare Advantage may be needed, particularly around provider networks and insurance authorization requirements.
But the study leaves an important question unanswered: What explains the lower transplant rates?
Until researchers can examine individual plans and the barriers patients encounter, that answer remains uncertain.
For patients and families, the immediate lesson is simpler. When choosing Medicare coverage, don’t stop at asking whether kidney transplants are covered.
Ask whether the plan gives you access to the doctors, hospital and treatment you may need to receive one.
