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CMS Moves to Expand Medicare Advantage Program Access to Individuals with End-Stage Renal Disease

On February 5, 2020, the Centers for Medicare and Medicaid Services (CMS) proposed removing long-standing prohibitions and eligibility restrictions that had barred many individuals with End-Stage Renal Disease (ESRD) from participating in the Medicare Advantage program.

Under the proposed rule, CMS is implementing certain statutory requirements of the 21st Century Cures Act (Cures Act) that expand Medicare Advantage (MA) coverage for ESRD patients, a population that has had limited access to the program.  

From the beginning of the MA program, CMS has excluded individuals with ESRD from enrollment in MA plans, subject to narrow exceptions. For instance, if an individual developed ESRD while enrolled in an MA plan or in a health plan offered by the MA organization, he or she could either remain in that MA plan or elect to enroll in another health plan offered by that organization. In most other circumstances, the individual would be out of luck – only able to enroll in Original Medicare (Parts A & B). The Cures Act, however, amended the Social Security Act to allow all Medicare eligible individuals with ESRD to enroll in MA plans, beginning January 1, 2021.

The proposed rule aims to codify the Cures Act and give all beneficiaries with ESRD the option to enroll in an MA plan starting in 2021. Also effective plan year 2021, MA organizations will no longer be responsible for their beneficiaries’ costs for organ acquisitions for kidney transplants. Instead, Original Medicare will cover the kidney acquisition costs for MA beneficiaries and such costs will be excluded from MA benchmarks.  

CMS is accepting comments on the proposed rule through April 6, 2020. Stakeholders should review the rule carefully and submit any comments by the deadline. The Arent Fox Health Care group has deep experience in the renal industry and regularly advises its client on submitting comments to CMS. 

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