Is Medicare Advantage a Plus for People on Dialysis?
When Medicare HMO plans came into being in the 1970s, members of the renal community were concerned that insurance companies operating them might put other interests ahead of the needs of the members they were established to serve. Nothing changed when these plans were renamed Medicare + Choice in 1997 and Medicare Advantage (MA) in 2003.1
Are MA plans workable today for those on dialysis? Here are some questions to consider:
How are MA plans paid? Medicare pays more to insurance companies that administer MA plans than what it costs traditional Medicare to treat people. This creates a burden to taxpayers—with no improvement in care quality.2
Does the MA plan follow CMS rules described in the Medicare Managed Care Manual? 3
With an average of three or more chronic health conditions, people with CKD need access to specialists. Do MA plan primary physicians offer timely referral to nephrologists and other specialists for people with CKD?
Is the MA plan’s network of providers (dialysis, physicians, hospital, pharmacies, etc.) appropriate and accessible for the patient—and is it stable or could it change? According to the Medicare website, providers can drop out of plans and plans can change networks anytime during a year. This could require a patient to find a new provider.
Do the MA plans’ contracted dialysis facilities offer the dialysis options patients want?
Do MA plans’ drug formularies include common dialysis and transplant drugs and does the plan account drugs correctly to Part B or Part D? Anecdotally, transplant patients have reported incorrect accounting of immunosuppressants to Part D—causing them to reach the “doughnut hole” sooner, and have to pay full price for these costly drugs.
Does the MA plan cover non-emergency transportation to dialysis?
Does the MA plan have a case manager who works with all ESRD patients?
What are the MA plan’s copays for dialysis? Does the plan have a patient assistance program to waive or help cover dialysis copays and/or medication costs?
Are out-of-pockets costs more or less than with traditional Medicare? MA plans are allowed to have an annual maximum out-of-pocket of $6,700 (it can be lower)—and patients can’t have a Medigap plan to help pay. Yet, anyone who is age 65, with or without ESRD, who enrolls in traditional Medicare can buy a Medigap plan within 6 months of enrolling in Part B and have lower out-of-pocket costs than in an MA plan. The following table, revised from the chart on the Medicare website, lists only the states that do require companies to sell Medigap plans to those under 65 with ESRD.
*A Medigap policy is only available to people under age 65 with ESRD.4
If your state isn’t on this list, check with your state insurance department or state health insurance assistance program to see if there may be a company that sells a Medigap policy to an ESRD patient. It’s likely to have a higher premium and may require patients to meet a waiting period for pre-existing conditions. The Patient Protection and Affordable Care Act did not address Medigap plans.
HR5659—Medicare “Choice” or Empty Promise?
On July 7, 2016, Jason Smith (R-MO), John Lewis (D-GA), Gus Bilirakis (R-FL), and Kurt Schrader (D-OR) introduced HR 5659, called Expanding Seniors Receiving Dialysis Choice Act of 20165, in the House of Representatives. Kidney Care Partners6 and its members, including dialysis providers, suppliers, manufacturers, and some nonprofit organizations including patient groups that give KCP higher credibility, are lobbying for this bill.
Dialysis providers want ESRD patients to be allowed to 7“choose” to enroll in MA plans. What is their motivation? Dialysis providers with more MA members may make more money if MA plans don’t bundle drugs and labs like traditional Medicare does. Also, dialysis patients who are members of MA plans may be locked into a certain dialysis corporation’s clinics if that’s the only contracted provider. This could require rural patients to travel long distances or patients to not get the treatment of their choice. Is the “choice” in this bill an empty promise?
On a related note, the Government Accountability Office (GAO) has repeatedly investigated MA plans and found that the government’s risk adjustment of MA payments based on how ill its members are has led to provider “upcoding,” defined as “A fraudulent practice in which provider services are billed for higher CPT procedure codes than were actually performed, resulting in a higher payment by Medicare or 3rd-party payors.” According to the GAO, MA plans that provide unsupported documentation of diagnoses cost the federal government $14.1 billion in 2013 alone.8 As the saying goes, follow the money when looking at the benefits and risks to evaluatie a major proposed change in policy like this bill.
Knowledge@Wharton, Why Consumers Don’t Gain Much from Medicare Advantage, June 20, 2014, http://knowledge.wharton.upenn.edu/article/medicare-advantage-offer-much-advantage/, Accessed August 3, 2016↩
Centers for Medicare & Medicaid Services, Medicare Managed Care Manual, 100-16, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html, Accessed August 3, 2016.↩
When Can I Buy Medigap? https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/when-can-i-buy-medigap.html, Accessed August 3, 2016.↩
Expanding Seniors Receiving Dialysis Choice Act of 2016, HR 5659, https://www.gpo.gov/fdsys/pkg/BILLS-114hr5659ih/pdf/BILLS-114hr5659ih.pdf, Accessed August 3, 2016.↩
Upcoding, http://medical-dictionary.thefreedictionary.com/upcoding, Accessed August 3, 2016.↩
General Accountability Office, Medicare Advantage: Fundamental Improvements Needed in CMS's Effort to Recover Substantial Amounts of Improper Payments, GAO-16-76: Published: Apr 8, 2016. Publicly Released: May 9, 2016, http://www.gao.gov/assets/680/676441.pdf, Accessed August 3, 2016.↩