Regulatory Policy

Enhance Patient Choice & Education

Dialysis patients must have access to a variety of appropriate treatment modalities and coverage options – regardless of age. Policy barriers that discourage patients from using certain forms of coverage and treatment modalities––including home dialysis––should be eliminated or revised.

Protect Patients Against Insurance Discrimination

KCP asks the Administration to ensure that insurance plans do not discriminate against dialysis patients and that patients can continue to have a choice in coverage — whether Medicare, private insurance, group health insurance, or any other option — that best meets the needs of the patient and his/her family.

Further, patients should have the ability to obtain Medigap coverage and to choose Medicare Advantage if they wish. To that end, KCP urges Congress to guarantee access to Medigap for ESRD beneficiaries under 65 and allow ESRD patients to have earlier access to Medicare Advantage plans by moving up the implementation in the new law by one year to 2020.

The right of individuals under age 65 with kidney failure to continue to have the ability to maintain their private health insurance, to be able to seek and obtain charitable assistance, and to maintain access to premium tax credits should be protected. This policy is consistent with the long-standing objective of ensuring that individuals with kidney failure who are under 65 years old have the right to select the health plan that best meets their health care needs.

Low-income patients are under attack by insurer attempts to decrease charitable premium assistance (CPA), which plays a key role in allowing patients to determine the best insurance coverage option for themselves and families. Large health plans have targeted CPA by encouraging dialysis patients to forgo private insurance and enroll in Medicare or Medicaid instead. As of June 2018, a mere 8% of ESRD patients receiving assistance were enrolled in a commercial plan. ESRD patients must maintain their choice of care and coverage, while payors should continue to provide appropriate payments for treatment. 

Insurance Parity

In addition, KCP supports insurance parity and coverage for individuals with kidney failure who purchase insurance through the Health Insurance Exchanges. Parity should mean that individuals in the Exchanges have the ability to maintain their private coverage for thirty months after diagnosis with kidney failure, a diagnosis that makes them eligible for Medicare. The Department of Health and Human Services (HHS) clarified in the Final Rule on the Establishment of Exchanges and Qualified Health Plans (CMS-9989-F) that MSP rules apply in the small group market.

Parity means that individuals with kidney failure have the same access to tax credits and subsidies as do other Americans within the Exchanges. It also means that individuals with kidney failure enrolled in these plans are not discriminated against when it comes to having access to the providers, services, and items they need.

Private Insurance Coverage

Given the importance of private coverage to the dialysis patient population, the Center for Consumer Information and Insurance Oversight (CCIIO) should maintain the federal commitment to Americans living with kidney failure by ensuring that coverage for ESRD is expressly included as an essential health benefit. Americans with life-threatening kidney failure should have access to coverage for ESRD in plans offered through the Exchanges.

Furthermore, policymakers must continue to address barriers that make it difficult for many patients to receive appropriate care. KCP has crafted in-depth issue briefs and insightful comment letters to help guide federal policies, which we have shared with federal stakeholders including the Centers for Medicare and Medicaid Services (CMS).

Patient Education

In order to fully appreciate the power of patient choice, patients must also have access to clear, easy-to-understand information that can help them decide on the best option for them. Patients must continue to have access to up-to-date facts about available treatment options and settings for treatment.

Effective educational intervention is central to informed patient decision making, effective management of co-morbidities and uremic complications, and enhanced patient involvement in health care. By respecting patients’ autonomy and the power to choose their own care, health care professionals can honor patient dignity and help them feel more confident and informed about their treatment options. Moreover, effective education has the potential to delay the onset of dialysis by equipping patients with information to manage their diseases, improve patient quality of life by promoting healthy habits, and reduce Medicare program costs by lowering the need to conduct as many costly procedures.

In addition, KCP supports efforts to provide patients and the public with accurate, easy-to-understand information about dialysis facility quality and quality of care offered. Recognizing shortcomings in the current system for rating dialysis facilities, KCP supports reforming ESRD facility quality programs that support informed decision-making so that patients are able to enjoy accurate and meaningful information.

At the present time, there is considerable confusion about the relationship between the ESRD Quality Improvement Program (QIP), a pay-for-performance/value-based purchasing program, and the Dialysis Facility Compare (DFC) program, a public reporting program. To address this problem and, most importantly, to empower patients and provide them with reliable tools they can use to make decisions about their health care, KCP recommends that CMS separate the programs clearly by using different measures in each program, using the star ratings based on the ESRD QIP penalty distribution, and improving the functionality of the DFC website.

Specifically, ESRD QIP public reporting certificates required by the statute should be returned to the previous format that includes meaningful information, not just the number that provides patients with no specific information on the measures. If CMS continues to promote star ratings, the stars should be incorporated into the ESRD QIP certificates and be set using the QIP penalty distribution, using NQF-endorsed measures so that patients understand the specific factors that influence ESRD facility ratings. Moreover, the DFC should be return to its congressionally-intended quality assurance mission and provide a more detailed and comprehensive assessment of facilities that can be accessed in a manner that allows users to tailor the results to their individual needs. The DFC should include QIP measures, as well as important measures that are not included in the ESRD QIP. The DFC website should be improved in a way that allows patients and caregivers to understand the site and use it more often.

Comment Letters: