Supreme Court ruling on dialysis paves way for coverage limits

A Supreme Court ruling that greenlit limited private health plan dialysis coverage may pave the way for other insurers to reduce payment for kidney care and other Medicare-covered treatments.

The high court rejected a challenge low reimbursements from an employer-sponsored health plan for dialysis, which the plaintiff claims discourages providers from joining its network and effectively drives policyholders to enroll in Medicare instead.

This legal ruling offers a playbook that other group health plans could follow in designing benefit packages to encourage people with end-stage kidney disease to forego private coverage in favor of Medicare, which is available for all person suffering from chronic renal insufficiency whatever their age. . And the ramifications may extend beyond dialysis patients.

“This is a precedent that could have broad downstream impacts that could not only affect people with kidney failure who need treatment, but potentially other Medicare benefits,” said Dr. Joseph Vassalotti, physician- head of the National Kidney Foundation and professor. at the Icahn School of Medicine at Mount Sinai.

If more insurers adopt reimbursement policies similar to the Marietta Memorial Hospital Employee Health Benefits Plan and more people switch to Medicare, dialysis centers could close because the public problem is not paying enough for support them, Vassalotti said. On Tuesday, the Centers for Medicare and Medicaid Services offers A 3.1% increase in the health insurance rate for dialysis providers in 2023.

Thirty-seven million people in the United States have kidney disease, and 97% of those who develop the disease receive dialysis, according to the most recent data from the US Renal Data System.

The annual cost of treating ESRD was $53,717 in 2019, according to the US Renal Data System. Patients with chronic kidney disease often suffer from several other conditions, such as diabetes, heart disease, and lung disease. Many are older, frail and face socio-economic barriers to medical care.

People enrolled in paid health insurance with ESRD must pay 20% of their dialysis costs. Beneficiaries can purchase additional policies, although some states limit the availability of these plans to people under age 65. Beneficiaries can also opt for Medicare Advantage plans, which have more limited networks than traditional health insurance but also require lower cost sharing for dialysis.

From 2015 to 2018, 13% of patients with chronic kidney disease had only private health insurance, according to the US Renal Data System. Nearly 37% were enrolled in both private plans and Medicare and 37.5% had Medicare alone.

“It’s not like someone is dying in the ER waiting for coverage. Medicare will pay,” said Jen Jordan, a lawyer who specializes in Medicare Secondary Payer Act cases. “The only concern I would have is that plans are more inclined to write simpler benefits now that they know the Supreme Court supports such an outcome.”

In a ruling on Tuesday, the High Court dismissed a 2018 lawsuit brought by dialysis provider DaVita that challenged the benefit design of the employee health benefits plan at Marietta Memorial Hospital in Ohio for employees with end-stage renal disease.

According to DaVita, the plan violates the Medicare Secondary Payer Act, which states that the public program must reimburse only for services not covered by enrollees’ other health coverage. Under federal law, employer-sponsored health plans must cover workers with kidney failure for 33 months before Medicare becomes the primary payer.

But the Supreme Court ruled 7-2 that the plan is legal because it does not explicitly differentiate benefits for people with chronic kidney disease and those without. Justices Elena Kagan and Sonia Sotomayor dissented, writing that ambulatory dialysis is a “near-perfect proxy” for a diagnosis of end-stage kidney disease, making the plan discriminatory against such patients.

“Congress will have to fix a law that the court violated,” Andrew Conkling, chairman of the board of directors of the industry-backed advocacy organization Dialysis Patient Citizens, said in a press release. “We will return to Congress with other ESRD patient advocates to immediately clarify the rules once and for all.”

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