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CMS Proposes Changes for Payments, Policies Affecting Medicare Dialysis Programs

Allison Inserro
CMS proposed new rulemaking Wednesday to update 2019 Medicare payment policies for fee-for-service patients with end-stage renal disease (ESRD).
CMS proposed new rulemaking Wednesday to update 2019 Medicare payment policies for fee-for-service patients with end-stage renal disease (ESRD). CMS projects the changes will increase the total payments to all dialysis facilities as well as freestanding facilities by 1.7%; for hospital-based dialysis, CMS projects an increase in total payments of 1.8%.

In addition, CMS is proposing an expansion of a payment adjustment for dialysis drugs it said will “provide beneficiaries with more choices, promote innovation, and lower prices through competition.”

All new renal dialysis drugs and biologic drugs as of January 1, 2019, regardless of whether they fit into an existing functional category, will be eligible for the transitional drug add-on payment adjustment (TDAPA). After the end of the 2-year TDAPA period, modifications to the ESRD base rate would not be available for new drugs that fall within existing functional categories.

A new injectable or intravenous drug or biological used for ESRD for which there is no current functional category and is not considered accounted for in the ESRD prospective payment base rate is paid using a TDAPA.

CMS also said it is removing 4 related quality measures, most of which are topped out. The measures are healthcare personnel influenza vaccination, pain assessment and follow-up, anemia management, and serum phosphorus. It is proposing to add new quality measures in future years: percentage of prevalent patients waitlisted, medication reconciliation for patients receiving care at dialysis facilities, and standardized first kidney transplant waitlist ratio for incident dialysis patients. 

CMS is also changing its bidding process for durable medical equipment (DME), prosthetics, and orthotics. It is creating new payment classes for oxygen and oxygen equipment and a new methodology for ensuring that the classes are budget neutral; special payment rules for multi-function ventilators or ventilators that perform functions of other DME.

Since CMS has yet to start the process for is new contracting system, beneficiaries can receive items from any willing supplier until the new contracts are awarded.

Currently, supplies of DME set prices on equipment as a package—for instance, a powered wheelchair and all of its accessories. Under the proposed change, CMS would switch to a process called lead item bidding, where only a bid would be accepted on the main item (ie, wheelchair). Set prices for accessories would be based on a fee schedule.

CMS Administrator Seema Verma said more than 500,000 Medicare beneficiaries have ESRD.

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