Medicare Advantage

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In a letter to Administrator Seema Verma of the Centers for Medicare & Medicaid Services (CMS) last month, ASN expressed its support for Medicare Advantage (MA) expanding access to allow patients with kidney failure to enroll in MA beginning in January 2021. These expanded plans can enable patients to access more choices and additional benefits such as transportation assistance, greater care coordination, or even dental care.

In the MA final rule, CMS took several steps affecting network adequacy in MA plans with some provisions potentially affecting kidney care coverage. The step that has drawn the most attention in the kidney community is CMS’ decision to not include maximum time and distance standards for outpatient dialysis to achieve network adequacy in MA plans.

ASN had supported CMS’ bold language in the proposed rule to reconsider how to achieve network adequacy allowing for the inclusion of innovation in care delivery, increased use of telehealth, and home dialysis. However, the step to totally and immediately remove these in-center facilities from those requirements in MA plans did surprise many.

Members of the kidney community and ASN are voicing some concerns that this step could have unintended consequences that affect dialysis patients. Patients utilizing home dialysis are sometimes transitioned to in-center hemodialysis or need access to in-center facilities for a limited period of time. In such cases, there is concern that patients may not be able to see their nephrologist, could face higher out-of-network costs under a MA plan, and could have a substantial transportation burden.

Highlighting these concerns to CMS, ASN urged the agency to use its authority to maintain safety guardrails for patients and ensure the transparency needed to guarantee greater patient access to MA plans. ASN also urged that CMS continue to uphold existing policy to allow for equal access to healthcare choices, including the following: Ensuring access to all necessary dialysis care (including in-center care) in accordance with community standards of care (recognizing that the community standard of care in San Ysidro, New Mexico, may look substantially different than the community standard of care in San Francisco, California, for example).

ASN also encouraged CMS to aggressively use the Medicare Office of the Ombudsman to not approve plans constructed to avoid geographic areas with higher concentrations of Medicare/Medicaid dual eligible, and that reliance on hospital-based dialysis care only is not an acceptable substitute for meeting community standards of care for in-center hemodialysis.

To best evaluate the MA plans, ASN urges patients considering MA to review the healthcare professionals and dialysis organizations included in the available MA plans’ in-network coverage.