Background

Starting in 2021, the 21st Century Cures Act allows beneficiaries diagnosed with ESRD to enroll in MA plans. Prior to 2021, most beneficiaries with ESRD enrolled in MA are those who developed ESRD after enrollment in a plan, patients who already received a transplant prior to enrolling in a plan, or those who choose to enroll in a Chronic Disease Special Needs Plan that specializes in ESRD. In addition, ESRD enrollees in a commercial employer plan who become Medicare eligible may enroll in an MA plan if it is owned by same parent organization under waiver authority.

Analysis

An Avalere analysis compared ESRD patients enrolled in MA in 2015 to ESRD patients enrolled in FFS in the same year. In 2015, approximately 301,000 FFS beneficiaries had ESRD (representing 0.99% of the FFS population), and just over 58,000 MA enrollees had ESRD (representing 0.36% of the MA population). Overall, Avalere found key differences between the 2 populations. These are illustrated in Table 1.

While some plans have experience managing the ESRD population because of current enrollment, differences in patient characteristics among ESRD patients enrolled in MA and those in FFS may result in differences in costs, comorbidities, and the types and intensity of services used. Avalere’s analysis did not look at utilization patterns of the 2 groups. However, the differences in the proportion of duals status suggest the underlying costs of the 2 populations may differ.

Understanding the differences between the MA enrollees and the FFS population may help plans better prepare for the 2021 transition. This analysis indicates that a higher proportion of dually eligible ESRD patients could enroll in MA, creating new challenges for plans. A previous Avalere analysis found that payments to MA plans for ESRD beneficiaries may be inadequate. Specifically, Avalere found that in 10 of the top 15 metropolitan statistical areas with the most ESRD patients, payment to MA plans would be less than the FFS spending on ESRD patients.

Methodology

Avalere analyzed the Medicare Beneficiary Summary File under a research data use agreement with CMS that captures beneficiary characteristics and enrollment information to identify beneficiaries with ESRD status in all 12 months of 2015 and all beneficiaries with 12 months Part A and Part B enrollment in either FFS or MA. Dual-eligibility status was assigned based on the plurality of months in 2015 when a beneficiary was dually eligible for Medicare and Medicaid.

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