As we may know, patients with end stage renal disease (ESRD) have, historically, not been allowed to enroll in Medicare Advantage plans. About 130,000 were grandfathered in through employer-sponsored coverage or developed it after enrolling in MA plans. That will change for 2021. The 21st Century Cures Act changed policy that allows ESRD patient MA Plan enrollment, and CMS estimates an additional 83,000 will sign up by 2026.
While this is undoubtedly good news for ESRD patients, the same sentiment doesn’t necessarily carry through to MA plans or risk-based providers. America’s Health Insurance Plans (AHIP), a trade organization for insurers, reports a medical loss ratio of 112% for ESRD patients in MA plans. The medical loss ratio is the percentage of the premium dollars spent on medical benefits, and is mandated by the PPACA to be at least 85%.
Some bright spots in this change for MA plans and providers are a carve out of the kidney acquisition costs for transplants; those will be paid by the Medicare program. Additionally, there is a proposal to allow MA plans more flexibility in managing their networks to reduce dialysis expenses.
This handy fact sheet from AHIP summarizes the policy change.