The Centers for Medicare & Medicaid Services has issued a request for information seeking public comment on concerns that some health care companies, including dialysis providers, and provider-affiliated organizations may be steering people eligible for, or receiving, Medicare and/or Medicaid benefits into Affordable Care Act-compliant individual market plans, including Health Insurance Marketplace plans, for the purpose of obtaining higher reimbursement rates.
Congress made sure in 1972 that anyone diagnosed with end-stage renal disease automatically qualified for Medicare benefits to get dialysis. Today, not all providers see that as a first choice for their patients, according to CMS.
“We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients’ needs,” said CMS Acting Administrator Andy Slavitt. “These actions can limit benefits for those who need them, potentially result in greater costs to patients, and ultimately increase the cost of Marketplace coverage for everyone.
One dialysis provider, American Renal Associates, is in a legal battle with insurer United Healthcare over allegedly persuading newly diagnosed patients to leave or bypass Medicare and Medicaid program and select UHC’s commercial ACA market plans instead. United says ARA has charged $4,000 a treatment for some of its patients when the typical reimbursement for Medicare and Medicaid plans is less than 10% of that rate. ARA asked the courts this week to dismiss the suit. American Renal, along with other providers, have complained for years that the Medicare payment for dialysis care is inadequate.
In a prepared statement, the National Kidney Foundation said, “The (NKF) is concerned about allegations of dialysis patients potentially being steered into health insurance options that primarily benefit the provider; but may not necessarily be in the best interests of the patient. We agree with CMS that “ ‘[E]nrollment decisions should be made, without influence, by the individual based on their specific circumstances, and health and financial needs.’ ”
In addition to asking for more information on instances of problematic steering of consumers to individual market plans, CMS says it is also considering potential regulatory and operational options to prohibit or limit premium payments and routine waiver of cost-sharing for qualified health plans by health care providers. CMS is considering impose civil monetary penalties on health care providers when their actions result in late enrollment penalties for Medicare eligible individuals who are steered to an individual market plan and, as a result, are delayed in enrolling in Medicare.
The letter to all dialysis providers can be found on the CMS website at: https://www.cms.gov/about-cms/components/cpi/downloads/rfi-medicare-dialysis.pdf