ESRD Choice Act of 2016

The ESRD Choice Act of 2016 (H.R. 5659) is designed to expand Medicare coverage options for dialysis patients. Under the ESRD Choice Act of 2016, introduced by Representatives Jason Smith (R-MO), John Lewis (D-GA), Gus Bilirakis (R-FL) and Kurt Schrader (D-OR), individuals who develop kidney failure would be given the same freedom of choice offered to other Medicare beneficiaries by allowing end-stage renal disease (ESRD) patients access to Medicare Advantage (MA) plans.

Under current law, individuals who become eligible for Medicare because they are diagnosed with ESRD are prohibited from enrolling in a MA plan. No other Medicare beneficiaries are prohibited because of their health status from having the choice to join MA plans. Since 2000, the Medicare Payment Advisory Commission (MedPAC) has recommended Congress eliminate this restriction.

Many patients would benefit from access to MA plans because many of these plans provide patients with coordinated care and access to additional benefits and services:

  • The ESRD Disease Management Demonstration found that Medicare beneficiaries with ESRD in managed care have clinical outcomes that are as good as or better than they would have in Medicare fee-for-service (FFS).  The vast majority of individuals with ESRD on dialysis are living with multiple chronic conditions, making care coordination clinically important.
  • Care delivery models are changing to promote coordinated care.  Medicare should ensure that individuals with chronic illnesses, including ESRD, have access to such coordination.
  • Although the Center for Medicare and Medicaid Innovation has proposed to implement a Comprehensive ESRD Care Initiative, the ESRD Seamless Care Organization (ESCO) model will not be available to all Medicare beneficiaries with ESRD.
  • The additional MA benefits and services offered vary by plan, but may include case management services, disease management programs, nurse help hotlines, and tools to address disparities in care for minorities, who comprise a disproportionate proportion of ESRD patients.  These are services that ESRD beneficiaries do not receive in Medicare FFS.

MA Plans also provide the most affordable coverage option for individuals with ESRD:

  • CMS requires MA plans to limit the out-of-pocket costs to $6,700 annually and the average out-of-pocket cost limit in a MA plan is $5,223.  FFS Medicare, on the other hand, does not have limits on out-of-pocket costs.
  • In 2010, ESRD beneficiaries spent an average of $6,918 annually on health care.
  • For dialysis patients without supplemental insurance coverage, out-of-pocket health care costs can exceed $9,000 per year.  Less than half of states require insurers to offer at least one kind of Medigap policy to Medicare ESRD beneficiaries younger than age 65.  In states where Medigap coverage is not available, MA coverage would help ensure affordable coverage for individuals with ESRD.
  • Approximately one-third of Medicare beneficiaries with ESRD have incomes that make them eligible for Medicaid.  MA is an important source of coverage for low-income beneficiaries.  Among Medicare beneficiaries enrolled in MA plans, 27 percent have an income less than $10,000, and 33 percent have an income between $10,000-$20,000.

Learn more about H.R. 5659:

Reference Documents:

Policy Documents

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