ESRD Enrollment Creates Cost, Network Unknowns for MAOs

As Medicare Advantage plans prepare to enroll patients with end-stage renal disease (ESRD) this fall, a recent change to network adequacy measurement will give them some flexibility in how they include dialysis care in their networks. Meanwhile, a new lawsuit challenging CMS’s decision to exclude outpatient dialysis facilities from time and distance standards suggests the move could dampen enrollment of ESRD patients in MA plans, but experts say a lot will depend on how they shop and what they’re looking for in coverage this fall.

Thanks to a provision in the 21st Century Cures Act, signed into law in 2016, some 300,000 ESRD patients will be eligible for MA coverage effective Jan. 1, 2021, whereas they were previously allowed in MA plans only for the plan year in which they were diagnosed or if they enrolled in a Special Needs Plan specifically designed to serve ESRD patients (RMA 2/20/20, p. 1).

© 2021 MMIT

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues, including drug benefits and specialty pharmacy, for more than a decade. She served as editor of Drug Benefit News (the predecessor to Radar on Drug Benefits) from 2004 to 2005 and again from 2011 to 2016, and now manages Radar on Medicare Advantage. Lauren graduated from Vassar College with a B.A. in English.

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