Recently the Centers for Medicare & Medicaid Services (CMS) announced it will investigate possible inappropriate efforts by providers of dialysis services to steer patients eligible for Medicare and Medicaid into insurance plans paid for by third parties. We think this is an important issue and we fully support the effort to make sure that there is no room for undue influence over patients in choosing their insurance.
But we also believe it is vitally important that people with ESRD should not be broadly excluded as a class from access to the insurance marketplace. Patients do have a choice. In discussing inappropriate access, we cannot forget about legitimate access.
In the course of the discussion, some have suggested that the problem is caused by charitable assistance for the payment of insurance premiums. We disagree. Many low-income, chronically ill patients (many of whom are disabled) depend on charities like the American Kidney Fund (AKF) to help pay for many of their expenses, including health care expenses. Cutting off this assistance would be particularly callous and would harm some of our nation’s most vulnerable people.
The kinds of concerns that have been raised are the very reason why AKF has put into place numerous guardrails that are designed to provide appropriate access to insurance as provided by law for people with kidney failure.
These guardrails were designed in accordance with guidance from Health and Human Services Office of the Inspector General that provided standards for third-party assistance in the payment of insurance premiums to bar specific practices that might steer patients into particular plans or to particular health care providers. For nearly 20 years we have taken a comprehensive approach to ensure the integrity of our program and we continuously look for ways to improve it. Too many patients depend on us to have it any other way.
CMS has made very clear in the past that ESRD patients who are eligible for Medicare may enroll in the Marketplace, so long as they choose not to enroll in Medicare. When CMS provided this option for ESRD patients to enroll in the Marketplace, its intent could not have been to effectively exclude any ESRD patients who could not personally afford the cost of premiums. Even with subsidies, premiums can be prohibitively expensive for the population we serve—a population that is overwhelmingly unable to work because of their medical condition. AKF has always been a safety net for our nation’s low-income dialysis patients, and under the ACA, our premium assistance makes Marketplace plans an option for low-income ESRD patients who are fighting for their lives.
Some have asked why an ESRD patient who is eligible for Medicare would choose a Marketplace plan in the first place. Choice of insurance is a personal matter, but the reasons are many. First and foremost, Medicare alone is not enough to cover medical costs for people living with ESRD. A supplemental plan is necessary to cover the 20 percent out-of-pocket costs that have no lifetime cap under Medicare. In about half the states, insurers are not required to offer Medigap to ESRD patients under age 65 and ESRD patients in all states are prohibited by law from enrolling in Medicare Advantage plans which provide comprehensive coverage. For these patients, a Marketplace plan may very well be the best option to cap out-of-pocket costs and to achieve effective coordination of care. In other cases, even if Medigap is available, a patient may choose a Marketplace plan because Medicare does not offer family coverage, or because the person seeks better access to transplantation, or because the physician network offered under the Marketplace allows the person to continue seeing the same doctors they saw before they became ill. The reasons are many and cannot be distilled down into a black-and-white declaration that people with ESRD belong on Medicare.
For us, the patient is always the focus and the effect on patients is what we care about—not insurance companies or dialysis providers, and not CMS—but the people those institutions are meant to serve. All ESRD patients must have access to the care they need to stay alive. What you will hear from AKF during the public discussion of this matter is that the goals of preventing steering—with which we agree—and preserving choice for low income-patients are not mutually exclusive.
For nearly 20 years we have continuously reviewed our program to ensure that our guardrails protect its integrity. That’s even more important in the changing health care landscape. We will do all we can during the examination of this issue by CMS to ensure that patient choice is not compromised and that the insurance needs of those who are poor and fighting for their lives against kidney disease are not forgotten.