In 1972 the United States Congress passed legislation authorizing the End Stage Renal Disease Program (ESRD) under Medicare. Section 299I of Public Law 92-603, passed on October 30, 1972, extended Medicare coverage to Americans if they had stage five chronic kidney disease (CKD) and were otherwise qualified under Medicare's work history requirements. The program's launch was July 1, 1973. Previously only those over 65 could qualify for Medicare benefits. This entitlement is nearly universal, covering over 90% of all U.S. citizens with severe CKD.[1]
Medicare's unit of payment is one composite rate per dialysis treatment. The ESRD composite rate payment system differs from most other prospective payment systems because there is a single product category to define the service Medicare is buying. Although different equipment, supplies, and labor are needed for hemodialysis and peritoneal dialysis, the current system does not differentiate payment based on dialysis method, location (home or incenter) or equipment used.[citation needed]
The composite rate is intended to cover all operating and capital costs that efficient providers would incur in furnishing dialysis in outpatient facilities or in beneficiaries' homes. The base composite rate as of 2006[update] is $130 for freestanding dialysis facilities. Medicare caps its payments to facilities at an amount equal to three dialysis sessions per week. Although home dialysis may be given more frequently it is not fully reimbursed by Medicare.[citation needed]
An add-on payment supplements the composite rate. It represents some of the profits previously associated with payments for separately billable drugs. The Social Security Act (Section 1881(b)), as amended by Section 623 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, directed revisions to the composite rate payment system as well as payment for separately billable drugs furnished by dialysis facilities. There is an annual update to the add-on payment which is determined administratively by CMS. Congressional Record 5827 updates the drug add-on payment. For 2008[update] the drug add-on payment to the composite payment rate increased from 14.9 percent to 15.5 percent.[2]
In addition to the add-on payment adjustment, which applies nationally, the composite rate is adjusted up or down by a geographic wage adjustment. (All beneficiaries at a given unit would have the same geographic wage adjustment.) The final adjustment is for case mix; certain beneficiary characteristics trigger composite rate adjustments. These are based on age (<18, 18–44, 45–59, 60–69, 70–79, ≥80 years), body surface area and body mass index.[1]
Medicare secondary payer provisionedit
The Medicare Secondary Payer provision of the ESRD program (also known as the ESRD Coordination Period) was enacted as part of the Omnibus Budget Reconciliation Act of 1981. MSP provides for a coordination of benefits period between Medicare and private health insurance plans for individuals entitled to Medicare solely on the basis of ESRD. If an individual is entitled to Medicare because of ESRD and is covered by an Employer Group Health Plan (EGHP), the EGHP is the first payer (primary) for the first thirty months. The 1981 legislation created an eighteen-month MSP period; the Balanced Budget Act of 1997 extended the eighteen-month period to thirty months. The EGHP is primary regardless of the number of employees and/or the Medicare beneficiary's employment status.[3]
Referencesedit
^ ab(PDF). MedPAC. September 2006. Archived from the original (PDF) on July 21, 2007.
^. Archived from the original on January 1, 2008. Retrieved January 12, 2008.
External linksedit
Reimbursement for Hemodialysis, Peter B. DeOreo September 25, 2006, at the Wayback Machine
April 11, 2024
stage, renal, disease, program, 1972, united, states, congress, passed, legislation, authorizing, esrd, under, medicare, section, 299i, public, passed, october, 1972, extended, medicare, coverage, americans, they, stage, five, chronic, kidney, disease, were, o. In 1972 the United States Congress passed legislation authorizing the End Stage Renal Disease Program ESRD under Medicare Section 299I of Public Law 92 603 passed on October 30 1972 extended Medicare coverage to Americans if they had stage five chronic kidney disease CKD and were otherwise qualified under Medicare s work history requirements The program s launch was July 1 1973 Previously only those over 65 could qualify for Medicare benefits This entitlement is nearly universal covering over 90 of all U S citizens with severe CKD 1 Contents 1 Dialysis reimbursement 2 Medicare secondary payer provision 3 References 4 External linksDialysis reimbursement editMedicare s unit of payment is one composite rate per dialysis treatment The ESRD composite rate payment system differs from most other prospective payment systems because there is a single product category to define the service Medicare is buying Although different equipment supplies and labor are needed for hemodialysis and peritoneal dialysis the current system does not differentiate payment based on dialysis method location home or incenter or equipment used citation needed The composite rate is intended to cover all operating and capital costs that efficient providers would incur in furnishing dialysis in outpatient facilities or in beneficiaries homes The base composite rate as of 2006 update is 130 for freestanding dialysis facilities Medicare caps its payments to facilities at an amount equal to three dialysis sessions per week Although home dialysis may be given more frequently it is not fully reimbursed by Medicare citation needed An add on payment supplements the composite rate It represents some of the profits previously associated with payments for separately billable drugs The Social Security Act Section 1881 b as amended by Section 623 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 directed revisions to the composite rate payment system as well as payment for separately billable drugs furnished by dialysis facilities There is an annual update to the add on payment which is determined administratively by CMS Congressional Record 5827 updates the drug add on payment For 2008 update the drug add on payment to the composite payment rate increased from 14 9 percent to 15 5 percent 2 In addition to the add on payment adjustment which applies nationally the composite rate is adjusted up or down by a geographic wage adjustment All beneficiaries at a given unit would have the same geographic wage adjustment The final adjustment is for case mix certain beneficiary characteristics trigger composite rate adjustments These are based on age lt 18 18 44 45 59 60 69 70 79 80 years body surface area and body mass index 1 Medicare secondary payer provision editThe Medicare Secondary Payer provision of the ESRD program also known as the ESRD Coordination Period was enacted as part of the Omnibus Budget Reconciliation Act of 1981 MSP provides for a coordination of benefits period between Medicare and private health insurance plans for individuals entitled to Medicare solely on the basis of ESRD If an individual is entitled to Medicare because of ESRD and is covered by an Employer Group Health Plan EGHP the EGHP is the first payer primary for the first thirty months The 1981 legislation created an eighteen month MSP period the Balanced Budget Act of 1997 extended the eighteen month period to thirty months The EGHP is primary regardless of the number of employees and or the Medicare beneficiary s employment status 3 References edit a b Outpatient Dialysis Services payment System PDF MedPAC September 2006 Archived from the original PDF on July 21 2007 Medicare Monthly Review dead link Cahaba GBA Archived from the original on January 1 2008 Retrieved January 12 2008 External links editReimbursement for Hemodialysis Peter B DeOreo Archived September 25 2006 at the Wayback Machine Retrieved from https en wikipedia org w index php title End Stage Renal Disease Program amp oldid 1212606095, wikipedia, wiki, book, books, library,
