Medicare Advantage plans and network adequacy for outpatient dialysis

Starting in 2021, individuals with end-stage renal disease (ESRD, or kidney failure) will be able to enroll in Medicare Advantage (MA) plans—a type of Medicare health plan offered by a private company that contracts with Medicare to provide all Part A and Part B benefits to a person who chooses to enroll in one. Many MA plans also provide prescription drug coverage. MA plans are an alternative option to enrolling in the traditional Medicare fee-for-service program. Prior to 2021, individuals with ESRD were prohibited from enrolling in MA except in limited circumstances, such as when a person was already enrolled in an MA plan prior to being diagnosed with ESRD.

The American Kidney Fund (AKF) strongly supports increased coverage options for ESRD patients, including this change that will enable beneficiaries with ESRD to select an MA plan if they decide that is the best option for their needs. MA plans can offer additional benefits unavailable in traditional Medicare that can be important factors in a beneficiary’s decision to enroll in MA, such as care coordination, vision and dental coverage, transportation and an annual out-of-pocket maximum. The cap on out-of-pocket expenses is particularly important for beneficiaries who live in one of the 20 states that do not guarantee access to Medigap supplemental insurance for ESRD beneficiaries under the age of 65. These beneficiaries face financial hardship because they lack access to the supplemental coverage needed to help pay the cost-sharing in traditional Medicare, which does not have an annual out-of-pocket spending limit.

In a final regulation released earlier this year, the Centers for Medicare and Medicaid Services (CMS) removed outpatient dialysis from its list of specialty facilities that are subject to MA network adequacy standards. These standards determine how many types of providers must be in a plan’s network, based on factors like travel time or the number of miles a beneficiary must drive to reach a provider’s office or facility. CMS also intends to require MA organizations to submit proof of an adequate network that provides the required access and availability to dialysis services, including outpatient facilities.

In our comment letter to the proposed rule, AKF supported maintaining the time and distance standards for outpatient dialysis and opposed CMS’ proposal because it would decrease those standards in a way that would make MA plans impractical for patients with ESRD, particularly for patients who choose in-center dialysis as their treatment modality.

We strongly believe that patients must be allowed to select the modality and treatment choice that is clinically appropriate for their health needs and their individual circumstances, whether it is in-center hemodialysis, home hemodialysis, peritoneal dialysis or transplantation. Eliminating outpatient dialysis facilities from time and distance standards could interfere with a patient’s ability to choose the modality that is right for them within the MA program. This CMS regulation would effectively place the choice of modality in the hands of plans, not patients, and would erect a significant barrier preventing many ESRD beneficiaries from selecting MA plans. Our CEO published an opinion column in Modern Healthcare urging a federal judge to rule in favor of a lawsuit against CMS requiring network adequacy standards to apply to dialysis care.

As ESRD beneficiaries consider their Medicare options with the upcoming fall open enrollments period, they should understand which outpatient dialysis providers may or may not be within an MA plan’s network.

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About the Author

Mike Ly

Mike Ly is the director of public policy at the American Kidney Fund.

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