Update my browser now. Remember me. When ESRD Medicare coverage begins When your ESRD Medicare begins depends on your treatment plan: If you start a home dialysis training program, sometimes called self-dialysis, you are eligible for Medicare starting the first day of the first month of the home dialysis program.
You must start the program before your third month of dialysis. Additionally, your doctor must state that they expect you can complete the program and will continue home dialysis after the program ends. If you receive dialysis at an inpatient or outpatient dialysis facility, you are eligible for Medicare starting the first day of the fourth month you receive dialysis. In addition, the provisions increased coverage of kidney acquisition costs and provided for more complete coverage of home dialysis costs.
MSP provides that, if a beneficiary has insurance other than Medicare, then the other insurer is responsible for medical costs prior to Medicare. Subsequently, it was raised to 18 months in , and then 30 months in In addition, OBRA resulted in the development of the composite rate payment system for dialysis.
This included an exceptions process which results in even higher payment levels, primarily to hospital-based facilities.
These rates remained largely unchanged until the Balanced Budget Refinement Act of , which increased the rates by 1. The development of quality of care measures did not take place in a vacuum.
In , the National Kidney Foundation published the Dialysis Outcomes Quality Initiative, a set of guidelines for adequacy of hemodialysis, adequacy of peritoneal dialysis, vascular access procedures, and treatment of anemia National Kidney Foundation, Based on these previous efforts, HCFA has developed a set of 16 performance measures. As previously noted, prior to the enactment of the legislation creating the ESRD program, there were severe limits on the number of persons who received treatment.
As a result, the ESRD patient profile prior to was much different than it became under Medicare. In , the dialysis population was predominantly male 75 percent , overwhelmingly white persons 91 percent , and very young 7 percent over the age of By , there were equal proportions of males and females, black persons accounted for 35 percent of patients, and 46 percent of the dialysis population were over the age of 55 Evans, Blagg, and Bryan, In addition to providing access to treatment more in line with the underlying renal disease burden, Medicare coverage greatly expanded the number of patients receiving treatment.
Early estimates of the program were that as many as 10, new patients would initiate therapy each year and that the program would level out at about 35, beneficiaries Klar, Program enrollment has far outstripped initial estimates. Program incidence number of new patients each year was over 14, in , approximately 32, in , approximately 65, in , and reached 75, in —over 7 times the initial estimates.
The reasons for this increase are not well understood and are generally referred to under the designation of expanded acceptance criteria. Expanded acceptance treatment criteria are evident in two major areas—age and diabetes. In one-fourth of newly treated patients were 65 years or over.
By , well over one-half of new patients were 65 years or over at the time of renal failure. In the years before the Medicare ESRD program, diabetes was usually considered a contraindication to treatment. By , persons whose renal failure was due to diabetes still accounted for only 10 percent of new patients. In , 45 percent of new patients had renal failure due to diabetes. This expansion has occurred without specific design or intent. It appears that, as nephrologists and dialysis centers became more successful at treating these more fragile patients, referrals for treatment increased accordingly.
As previously noted, the two basic therapies are dialysis and transplantation. From the beginning of the program until the mids, there were rapid increases in both the number of transplants and in transplant success rates Hariharan et al. As a result, the percent of patients with a functioning kidney transplant more than doubled, from 10 percent to 22 percent by Eggers, Since , growth in the number of transplants has slowed, largely because of the limitation in the number of donated cadaver kidneys.
Much of the growth in the number of transplants in recent years is due to increasing numbers of living donor transplants. Living donors accounted for 20 percent of all kidney transplants in and 34 percent in Thus, despite the fact that transplant success rates are improving, the ever increasing dialysis population has offset these transplant gains.
From to , the percent of Medicare ESRD beneficiaries with a functioning graft has remained largely unchanged. Despite this large increase in total expenditures, compared with the rest of the Medicare program, ESRD has been fairly successful at restraining per capita costs Eggers, Enrollment increases account for much of the unexpected increase.
By , the average ESRD patient was about 7. The reason for this is that during the s and s, when medical care inflation was usually in the double digits, two major parts of ESRD care, dialysis and physician care known as the monthly capitation payment , remained largely unchanged. The dialysis payment rate the composite rate , is lower in nominal terms in than it was in In inflation-adjusted terms, payment for dialysis is about one-third as great as it was in The large decrease in inflation adjusted payment rates for dialysis has raised the question of how this has affected quality of care Institute of Medicine, , Health Care Financing Administration, There has been no evidence of decreased quality of care.
Dialysis mortality rates have decreased in recent years United States Renal Data System, , from 28 percent in to 19 percent in Someone who receives a kidney transplant before needing to start dialysis pre-emptive can enroll in Medicare after the transplant and coverage will be retroactively effective to the day of the transplant. Three years after the successful transplant, Medicare coverage will end. People who receive a kidney transplant need to plan ahead to make sure they will have insurance coverage once their Medicare coverage ends.
After that, Medicare pays first , and their employer health plan will pay second. People eligible for Medicare are generally not able to enroll in a Medicare Advantage plan, unless they had coverage from a plan owned by the same parent company prior to becoming eligible for Medicare.
This means if someone does not have another plan that will pay after Medicare, he or she may not be able to purchase any other supplemental policy and will be responsible for paying all deductibles and coinsurance. People with ESRD can enroll in the Affordable Care Act Marketplace plans and receive tax credits and subsidies if they are financially eligible , but only if they do not enroll in Medicare. If they choose not to enroll in Medicare, they should not enroll in any part of Medicare.
Who pays first? The Latest. Medicare Watch. By Casey Schwarz. November 4, By Lindsey Copeland.
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