The "Restore Protections for Dialysis Patients Act" ensures fair healthcare coverage for individuals with end-stage renal disease by preventing discriminatory practices by private health plans and reaffirming that dialysis services should not be unfavorably singled out for coverage limitations.
Bill Cassidy
Senator
LA
The "Restore Protections for Dialysis Patients Act" aims to reinforce Medicare Secondary Payer protections for individuals with end-stage renal disease, preventing discriminatory practices by private health plans. It ensures that health insurance plans do not unfairly shift primary coverage responsibility to Medicare for these individuals. The bill clarifies that singling out dialysis services for unfavorable treatment is an inappropriate differentiation in benefits, while maintaining the plan's ability to manage its provider network.
Bill Targets Insurance Rules to Protect Dialysis Patient Coverage, Prevent Cost-Shifting to Medicare
This bill, the "Restore Protections for Dialysis Patients Act," steps in to clarify the rules for health insurance plans covering individuals with end-stage renal disease (ESRD), the stage of kidney failure requiring dialysis or transplant. The main goal is to reinforce existing protections under the Medicare Secondary Payer rules, essentially making sure private group health plans don't discriminate against ESRD patients or try to push their costs onto Medicare prematurely.
Keeping Coverage Fair for Kidney Care
The core of the legislation amends Section 1862(b)(1)(C) of the Social Security Act. It explicitly states that group health plans cannot offer different benefits to individuals with ESRD compared to other people covered under the same plan. Think of it this way: if your plan covers treatment for heart failure or cancer at a certain level, it shouldn't single out dialysis for significantly worse coverage, higher co-pays, or stricter limitations just because the condition is ESRD. The bill language emphasizes that treating dialysis differently in a way that disadvantages ESRD patients is considered inappropriate differentiation.
What This Means for Health Plans (and Medicare)
This act reaffirms that private group health plans generally must act as the primary payer for individuals with ESRD for a specific coordination period (typically 30 months) before Medicare takes over that primary role. The bill prohibits plans from designing benefits in a way that effectively encourages ESRD patients to drop private coverage and rely solely on Medicare earlier than intended. For someone newly diagnosed with ESRD who has employer-sponsored insurance, this means their plan should cover dialysis costs according to its standard terms, just like any other major medical need, during that initial period. Importantly, while ensuring non-discrimination in benefits, the bill also clarifies that health plans aren't forced to include any specific dialysis clinics or a minimum number of them in their provider network, maintaining some flexibility in network design.