The federal government has introduced a rulemaking proposal to expand Medicare coverage to include in-home dialysis for patients with acute kidney injury.
The Centers for Medicare & Medicaid Services (CMS) announced on June 27 that they have issued a proposed rule, set to be published in the Federal Register on July 5, updating payment rates and policies of the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for 2025.
In addition to a 2.2 percent increase in overall expenditures on the ESRD payment system in 2025, amounting to approximately $170 million, the update includes a proposal to expand dialysis treatment options for Medicare beneficiaries with acute kidney injury.
CMS is proposing to allow Medicare beneficiaries with acute kidney injury to receive dialysis at home in 2025. They also suggest that dialysis facilities be permitted to bill Medicare for training patients with acute kidney injury to perform in-home dialysis. The agency plans to update the payment rate for acute kidney injury dialysis to $273.20, the same as the base rate for regular dialysis.
This proposal signifies a significant policy shift for CMS since current Medicare rules only cover in-center dialysis for beneficiaries with acute kidney injury who are not hospitalized.
CMS stated in the announcement that patients dependent on dialysis with acute kidney injury have the potential to recover kidney function and avoid long-term dialysis. By offering more flexible treatment options such as in-home dialysis, CMS aims to promote more frequent dialysis at lower ultrafiltration rates to support kidney function recovery in patients with acute kidney injury.
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If approved, Medicare coverage for home dialysis will be accessible to both patients with acute kidney injury and end-stage renal disease.
The public comment period for the proposed rulemaking is open until August 26, 2024.
ESRD Payment System Updates and Other Details
The proposed rule includes various updates to the ESRD PPS base rate.
CMS’s proposal aims to raise the base rate to $273.20 in 2025 from $271.02 in 2024, incorporating a 1.8 percent market basket percentage increase adjusted for productivity.
The agency anticipates that the updates will lead to a 2.2 percent increase in total payments to all ESRD facilities next year compared to 2024. Hospital-based ESRD facilities are expected to see a 3.9 percent increase in total payments, while freestanding facilities will experience a total payment increase of 2.1 percent.
CMS also intends to update the policy regarding handling unusually high costs, or outliers, in providing kidney dialysis services. They plan to include more specialty drugs and biological products in the list of services considered for extra cost adjustments, items that were or would have been included in the composite rate before the current ESRD payment system was established.
The agency is proposing technical changes to how it calculates the extra cost amounts, which consist of the outlier services fixed-dollar loss (FDL) amounts and the Medicare allowable payment (MAP) amounts, to better align with current data and costs.
For children, the threshold for FDL extra payments would increase from $11.32 to $223.44 in 2025, while the MAP payment rate would rise from $23.36 to $58.39.
For adults, the FDL extra payment threshold would decrease from $71.76 to $49.46, and the MAP payment rate would decrease from $36.28 to $33.57.
CMS also plans to revise the ESRD PPS-specific wage index methodology for the next year to better reflect geographic variations in labor costs using data from the Bureau of Labor Statistics and Medicare cost reports.
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