End Stage Renal Disease (US Federal Program)

End Stage Renal Disease (US Federal Program)

In 1972 the US Congress passed legislation authorizing the End Stage Renal Disease (ESRD) program under Medicare. Section 299I of Public Law 92-603, passed by Congress 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 US citizens with severe CKD. [http://www.medpac.gov/publications/other_reports/Sept06_MedPAC_Payment_Basics_dialysis.pdf MedPAC ESRD program overview]

Dialysis Reimbursement

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.

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 beneficiary's homes. The base composite rate as of 2006 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.

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 the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA, Section 623), directed revisions to the composite rate payment system as well as payment for separately billable drugs furnished by dialysis facilities. There is an annually update to the add-on payment which is determined administratively by CMS. Congressional Record 5827 updates the drug add-on payment, for 2008 the drug add-on payment to the composite payment rate will increase from 14.9 percent to 15.5 percent. [http://www.empiremedicare.com/pdf/combined/mmr2008-1.pdf Medicare Monthly Review]

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. [http://www.medpac.gov/publications/other_reports/Sept06_MedPAC_Payment_Basics_dialysis.pdf MedPAC ESRD program overview]

Medicare Secondary Payer Provision

The Medicare Secondary Payer provision of the ESRD program (also know 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. [http://www.cahabagba.com/part_b/msp/providers_general_info.htm Cahaba GBA]

References

External links

[http://www.empiremedicare.com/mspro/esrd/cc.htm Examples of ESRD Coordination Periods]

[http://www.aami.org/publications/HH/Reimbursement.DeOreo.pdf Reimbursement for Hemodialysis,Peter B. DeOreo]


Wikimedia Foundation. 2010.

Игры ⚽ Нужно решить контрольную?

Look at other dictionaries:

  • End stage renal disease — may refer to:* End stage renal disease, also known as chronic kidney disease (CKD), specifically the fifth stage of CKD * End Stage Renal Disease (US Federal Program), a type of federal insurance in the United States that covers people who… …   Wikipedia

  • Health and Disease — ▪ 2009 Introduction Food and Drug Safety.       In 2008 the contamination of infant formula and related dairy products with melamine in China led to widespread health problems in children, including urinary problems and possible renal tube… …   Universalium

  • Medicaid — Not to be confused with Medicare. Centers for Medicare and Medicaid Services (Medicaid administrator) logo Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means tested program… …   Wikipedia

  • Home hemodialysis — (HHD), is the provision of hemodialysis in the home of people with stage 5 chronic kidney disease. In the US home hemodialysis was the most common method of renal replacement therapy in the early 1970s before the introduction of the Federal ESRD… …   Wikipedia

  • Hemodiálisis domiciliaria — La hemodiálisis domiciliaria (HHD), es el suministro en el hogar de la hemodiálisis para el paciente con insuficiencia renal terminal. En la mayoría de los casos, es para los pacientes que desean mayor libertad de horarios y no tienen… …   Wikipedia Español

  • Organ donation — Intervention Organ donation is the donation of biological tissue or an organ of the human body, from a living or dead person to a living recipient in need of a transplantation. Transplantable organs and tissues are removed in a surgical procedure …   Wikipedia

  • Medicare (United States) — President Johnson signing the Medicare amendment. Former President Harry S. Truman (seated) and his wife, Bess, are on the far right …   Wikipedia

  • Indigenous Australians — This article is about the original inhabitants of Australia. For the Australian definition in law, see Australian Aborigines. Australian Aboriginals and Torres Strait Islanders …   Wikipedia

  • Socialized medicine — is a term used to describe a system for providing medical and hospital care for all at a nominal cost by means of government regulation of health services and subsidies derived from taxation.[1] It is used primarily and usually pejoratively in… …   Wikipedia

  • Acronyms in healthcare — v · d · …   Wikipedia

Share the article and excerpts

Direct link
Do a right-click on the link above
and select “Copy Link”