This bill restores protections to prevent private health insurance plans from discriminating against dialysis patients with End-Stage Renal Disease (ESRD) or shifting their treatment costs unfairly onto Medicare.
Mike Kelly
Representative
PA-16
The Restore Protections for Dialysis Patients Act aims to prevent private health insurance plans from discriminating against patients with End-Stage Renal Disease (ESRD). This legislation clarifies that plans cannot offer worse benefits or unfairly limit coverage for dialysis treatments compared to other medical services. Furthermore, it stops these plans from shifting the primary financial responsibility for ESRD care onto Medicare. The bill maintains existing rules ensuring fair treatment while preserving a health plan's ability to select its network of dialysis providers.
Dialysis Protection Bill Stops Insurers from Shifting Costs to Medicare, Mandates Fair Coverage
The “Restore Protections for Dialysis Patients Act” is essentially a policy backstop designed to protect people with End-Stage Renal Disease (ESRD) from getting the short end of the stick from their private group health insurance. Think of it as putting up guardrails to ensure that if you need dialysis, your insurance plan can’t treat that specific service worse than they treat everything else they cover.
The Mandate for Fair Coverage
This bill’s main purpose is crystal clear: private plans cannot discriminate against ESRD patients. Specifically, Section 3 reinforces existing rules by stating that group health plans cannot offer different benefits or put limits on benefits simply because someone has ESRD. If your plan covers physical therapy with a $50 copay and unlimited sessions, it can’t turn around and slap a $500 copay and a 10-session annual limit on your necessary dialysis treatments. This ensures benefit parity, meaning that the coverage level for dialysis must be comparable to other medical services covered by the plan.
Stopping the Medicare Cost Shuffle
Another major win for taxpayers and patients alike is the move to stop insurers from trying to offload their financial responsibility onto Medicare. When someone develops ESRD, they become eligible for Medicare, even if they are under 65. Historically, some private insurers have found ways to push the primary financial burden of dialysis care onto the government program. This Act clarifies that private plans must retain their responsibility to cover necessary care, preventing them from treating Medicare as the default primary payer for ESRD patients when they should be covering the costs themselves. This protects Medicare’s budget and ensures patients aren’t caught in a bureaucratic fight over who pays what.
The Network Catch: Provider Choice vs. Plan Control
Here’s where the bill gets interesting, balancing patient protection with insurer flexibility. While the Act mandates that group health plans cannot discriminate against ESRD patients in terms of benefits, it explicitly confirms that plans still have the right to control their provider networks. Section 3 states that this rule doesn't force a health plan to include any specific dialysis provider, or even a certain number of them, in their network.
What does this mean in practice? An insurer could comply with the benefit parity rules—offering great coverage for dialysis—but still limit the number of dialysis centers available to you in your area. For a patient living in a rural or suburban area, this could mean that while their coverage is technically excellent, they might have to drive significantly farther to the one or two centers that are in-network. Insurers retain the power to negotiate prices and select providers, which is good for cost control, but it might reduce patient choice and convenience.