Bill would lift Medicare Advantage restrictions on end-stage renal disease
Posted on September 23, 2016
A bipartisan bill introduced in the U.S. House of Representatives last week aims to open access to Medicare Advantage plans for patients with end-stage renal disease. The bill, known as the ESRD Choice Act (H.R. 5659), would allow enrollment in the Medicare managed care plans to ESRD patients undergoing dialysis treatment.
ESRD patients have been prohibited from joining predecessors of Medicare Advantage by a 1981 congressional restriction. At the time, health maintenance organizations were relatively unknown and untested outside of California, according to Jackson Williams, government affairs director for the 28,000-member patient advocacy and membership organization, Dialysis Patient Citizens.
Williams pointed out that some dialysis patients do receive care through Medicare Advantage plans, but those beneficiaries were diagnosed after turning 65 and were already covered by Medicare and allowed to remain in their MA plans.
Williams said a study of ESRD patients enrolled in Medicare Advantage programs and ESRD patients in Medicare fee-for-service found improved outcomes and lower mortality rates for the MA plan enrollees.
“We think it’s because of improved care coordination, which is not available to dialysis patients enrolled in traditional Medicare fee-for-service,” he said.
Williams said it’s unknown how many of the nation’s dialysis patients would enroll in Medicare Advantage plans if they had the option.
“This is not an auto-enrollment or mandatory enrollment, as in some Medicaid programs,” Williams said. “ESRD patients can stay or choose a Medicare Advantage plan.”
If the bill becomes law, Williams would advise ESRD patients to contact their state health insurance programs to investigate available plans and compare out-of-pocket limits to see whether they would end up saving money. He acknowledged that some MA plans have restricted provider networks.
“Our members would want to know whether they could keep the same doctors and go to the same dialysis centers,” he said.
Williams cited CareMore Medicare Advantage plans, which serve members in seven states. He said CareMore has reduced complications and hospitalizations for their ESRD patients in the company’s MA plans.
“We know there are other insurers who have made specific efforts to take care of this population, primarily by improving care coordination,” he said.
More than 660,000 Americans have been diagnosed with kidney failure, with 468,000 treated with dialysis. Nearly 200,000 are living with kidney transplants.
Medicare began to cover ESRD patients in 1972, even for those too young to normally qualify for Medicare. Medicare spent more than $50 billion on patients 65 and older with chronic kidney disease in 2013, according to the U.S. Renal Data System.
The bill has been endorsed by patient advocacy groups and the two largest insurance industry trade associations.
In a statement, the National Kidney Foundation noted the bill would “require education for individuals with end-stage renal disease (ESRD) to aid them in making informed decisions about MA coverage.”
The organization noted that ESRD patients are the only group specifically denied the option to enroll in Medicare Advantage plans. “Removing government restrictions that prevent ESRD patients from enrolling in MA plans will allow ESRD beneficiaries the same freedom of choice in coverage as other Medicare enrollees. Allowing ESRD patients to select these plans may help some patients minimize their out-of-pocket expenses and access additional benefits that some MA plans provide, like transportation and dental.”
Photo: Flickr user Helen Taylor