Tag Archives: Katherine Kroening

End-stage renal disease considerations for Medicare Advantage organizations as CMS expands eligibility

Currently, beneficiaries with ESRD are not allowed to enroll in MA plans except in limited situations such as enrolling in an ESRD special needs plan or remaining on the MA plan providing coverage prior to being diagnosed with ESRD. This results in a higher proportion of ESRD individuals receiving coverage through traditional Medicare (59%) relative to Medicare Advantage (14%).

However, starting in 2021, the distribution of ESRD individuals by coverage type may change. Section 17006 of the 21st Century Cures Act allows Medicare-eligible individuals with ESRD to enroll in MA plans as of January 1, 2021. This change in MA eligibility could shift a portion of ESRD individuals currently covered by traditional Medicare to an MA plan. 

MAOs could experience significant impacts to their overall financial results as the behavior, claim costs, and revenue payments for ESRD beneficiaries can vary greatly from non-ESRD beneficiaries. ESRD beneficiaries make up only 1% of Medicare enrollment and account for 7% of Medicare fee-for-service costs.

In this paper, Milliman consultants provide an overview of the upcoming ESRD MA eligibility change and key questions each MAO should consider when planning for 2021.