Patient group sues CMS, HHS over access to Medicare Advantage for patients with ESRD
Click Here to Manage Email Alerts
Dialysis Patient Citizens is suing HHS and CMS over policy language that may limit those with end-stage renal disease who want to join a Medicare Advantage plan to certain dialysis clinics.
In addition, the policy language may force some patients with existing plans to choose another dialysis facility.
The lawsuit against the two federal agencies notes the language thwarts the intent of Congress to open up Medicare Advantage (MA) plans to all patients on dialysis.
“ESRD patients successfully fought to get Congress to pass bipartisan legislation that would ensure they could enroll in Medicare Advantage in order to receive access to high-quality coordinated care at a more affordable cost currently available to everyone else,” Hrant Jamgochian, CEO of Dialysis Patient Citizens, said in a statement.
In the past, patients with ESRD could not join an MA plan unless they were already a beneficiary before getting kidney disease or were enrolled in a MA special needs plan that specifically serves patients older than 65 years with ESRD. In December 2016, Congress passed the 21st Century Cures Act that expanded MA to include all ESRD beneficiaries starting in January 2021.
Coverage for kidney transplants is also covered under MA plans and reimbursed under Parts A and B.
The new CMS regulatory language allows all patients with ESRD to join MA plans but eliminates time and distance limits for dialysis facilities from network adequacy requirements. That limits patients to selecting dialysis clinics included in a MA network, according to the lawsuit.
Ending the time and distance limit requirements “will limit patient choice and give ESRD patients no option but to remain in the fee-for-service program that can cost more out of pocket and offers spotty care coordination services,” Jamgochian said in the statement.
The Medicare Payment Advisory Commission, which endorsed opening MA to patients with ESRD in 2000, is opposed to the new HHS and CMS regulations.
“The commission strongly opposes the proposals to eliminate or alter time and distance standards for dialysis facilities,” Francis J. Crosson, MD, commission chair, wrote in a letter to CMS Administrator Seema Verma, MPH. “Network adequacy for ESRD beneficiaries is critical for ensuring access to MA plan options at a level that is equal to the level of access for other Medicare beneficiaries. Proximity to a dialysis facility is an important factor in dialysis care. Current distance standards vastly exceed typical travel times for ESRD beneficiaries in FFS Medicare and distances considered relevant under FFS Medicare’s low-volume payment adjustment. Finally, a large share of Medicare ESRD beneficiaries is already enrolled in MA, and it is unclear what problem is being addressed by eliminating or altering time and distance standards.”
In a letter to Azar and Verma, Kidney Care Partners, which opposes the regulations, said, “Under the policies in the final rule, [MA] plans could attest to having an adequate dialysis provider network by relying upon home dialysis only ... or hospital-based facilities (which might not have the capacity). By removing the minimum facility number requirement, CMS could create an opportunity for MA plans not to include any outpatient dialysis facilities ... [T]he finalized policy eliminating outpatient dialysis organizations from the network adequacy requirements could limit a beneficiary’s ability to make a ‘genuine choice’ of enrolling in an MA plan.
“It is not enough to have a plan attest to having access to an outpatient dialysis facility, there must be credible enforcement mechanisms that beneficiaries can trust to protect their access to necessary care.”
References:
- https://kidneycarepartners.com/press/kidney-care-partners-pleased-cms-implements-expansion-of-medicare-advantage-program-concerned-other-changes-could-undermine-care-access-for-patients-with-kidney-failure/
- https://www.dialysispatients.org/news/dialysis-patient-citizens-files-lawsuit-against-hhs-secretary-alex-azar-and-cms-administrator-seema-verma-over-new-regulation-that-undercuts-dialysis-patient-access-to-affordable-high-quality-care/
- www.medpac.gov/docs/default-source/comment-letters/04032020_ma_partd_comment_v2_sec.pdf?sfvrsn=0
Collapse
Read more about
Click Here to Manage Email Alerts