End Stage Renal Disease also known as kidney failure, affects more than 500,000 Medicare beneficiaries. Under old rules, Medicare Advantage plans have been unattainable to people with end-stage renal disease (ESRD) unless there was an ESRD Medicare Advantage Special Needs Plan offered in their area. People with ESRD are not currently eligible to enroll in a Medicare Advantage (MA) program. However, if the beneficiary acquired ESRD after enrollment or was grandfathered through employer-sponsored coverage, the beneficiary could be covered by a MA plan.
Beginning in 2021, more than the 300,000 Medicare beneficiaries with ESRD can enroll in MA plans. By law, MA plans are required to cover the same services as traditional Medicare but are allowed different costs and limitations. However, MA plans cannot set cost-sharing for any outpatient dialysis or immunosuppressant drugs higher than what would be the beneficiary obligation under traditional Medicare.
It is predicted that MA enrollment by individuals with ESRD will increase beginning in 2021, when a provision of the 21st Century Cures Act (Cures Act) removes the existing enrollment restrictions. CMS estimates that a sixty-three percent increase of people with ESRD will enroll in MA plans by 2026. Twenty-five percent of the population with ESRD on Medicare, have coverage through an MA plan currently.
As Medicare Advantage plans prepare to adapt to this increase in ESRD population and the needs of those patients, so should stakeholders, including the medical technology industry.
When contemplating a Medicare strategy for #medtech products, consider both traditional Medicare as well as Medicare Advantage. GIRS has worked with the top Medicare Advantage payers in the U.S. to help implement our clients’ Medicare strategies. As more patients become Medicare recipients and as Medicare Advantage grows, GIRS is #LookingAheadoftheCurve by educating clients about the potential impact on their payer mix and redefining payer market access strategies to secure Medicare coverage and preferred status for their products.
For more information, email us at info@girsinc.com or call us at 901-834-9119.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).
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About GIRS
For more than 17 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.