1. Beth Witten, MSW, ACSW, LSCSW Witten and Associates, LLC beth@wittenllc.com 1

2.  Resource & Policy Associate, Medical Education Institute, Inc. (consultant)  ESRD Training & Support Team member, Centers for Medicare & Medicaid Services, Survey & Certification Group (Federal contractor) 2

3. 3  Are you are 65 or older? OR  Received Security Disability or Railroad Retirement checks 2 years? OR  You need dialysis or kidney transplant? AND&  You or your spouse has enough Social Security work credits  A child’s parent has enough Social Security work credits

4.  Center hemodialysis  1st day of the 3 rd full month of dialysis  Peritoneal or home hemodialysis or self- care dialysis in-center  1 st day of the month dialysis starts if training starts before the first day of the 3 rd full month of dialysis 4

5. If you have an employer plan  Your employer plan pays first for the first 30 months you are eligible for Medicare, whether you enroll in Medicare or not If you have Medicare but no employer plan  Medicare pays first (primary) 5

6.  Original Medicare  Pays 80% under Part B for outpatient services, including dialysis after annual deductible  Medigap plan, Medicaid, individual plans can pay the deductible and all or part of the 20%  Medicare Advantage (MA)  Those who dialysis with an MA plan can keep it  Those on dialysis can join an MA Special Needs Plan  What you pay varies for deductibles, copays; may limit annual out-of-pocket costs (READ POLICY)  Can’t use a Medigap plan to pay unpaid costs 6

7.  20% of the composite rate for dialysis  20% of Part B covered drugs at dialysis or at home  Out-of-pocket costs for Part D drugs  $0 for most dialysis-related labs done at covered frequency  See Medicare Coverage for Kidney Dialysis & Kidney Transplant Services www.medicare.gov/Publications/Pubs/pdf/10128.pdf 7

8.  Anyone who receives outpatient dialysis and has:  Original Medicare OR  Any type of Medicare Advantage Plan  The bundle does not affect those with Medicare as their secondary payer 8

9.  You (or insurance) will pay 20% of the bundle for dialysis including what Dr. Wish described  When Medicare adjusts the rate, the 20% you (or insurance) pay goes up too  If you have certain health conditions  If you’re in the first 4 months of dialysis  If your clinic is rural or treats few patients 9

10.  Your doctor will still prescribe your drugs, but may prescribe more oral instead of IV drugs  You’ll get bundled drugs from your clinic or a pharmacy your clinic pays for your drugs  Remembering when and how to take more oral drugs may be challenging (dialysis patients take an average of 19 pills/day) 10

11.  Your clinic will still need to do labs to monitor your health  You’ll pay 20% of the total bundle amount, which includes payment for the average person’s dialysis-related labs  Medicare pays for your hepatitis B lab in the bundle no matter how often you need it  Your clinic can only bill you the 20% of the bundle & can’t bill you separately for any bundled lab, including hepatitis B 11

12.  Starting self-dialysis training before the 3 rd full month of dialysis gets Medicare from 1 st of the month dialysis started  Medicare pays more the first 4 mo of dialysis if you have it; the 20% is that much higher  No Method II—If you still get your equipment & supplies from a company (not your clinic), your clinic will pay the company & collect Medicare’s bundled payment  Medicare won’t pay for a home helper  Medicare won’t pay for more than 3 HD session/week without medical justification 12

13.  Will your clinic use more oral drugs & how will that affect your labs & how you feel?  Will your clinic reduce your dose of ESAs & how will that affect how you feel?  Will your clinic discourage you from traveling if their lab doesn’t charge a monthly fee for all labs?  Will there be a rural clinic closer to where you live?  Will your clinic start to offer in-center self-care? Will you be trained & do self-care in-center? 13

14.  If your clinic starts an in-center self-care program will you be encouraged to do self-care?  Will your clinic add home dialysis (PD or HD)?  Will your clinic encourage new patients to start home training to get Medicare sooner?  Will your clinic still be willing to train you for home dialysis after first 4 months?  Will your doctor medically justify 4 or more sessions/week to reduce your need for some drugs and lower the chance you’ll need to be hospitalized? 14

15.  Will the payment be enough to:  Promote greater innovation in kidney care  Increase staffing so you get more individualized care  Encourage clinics to use social workers to help you overcome barriers to work so you can keep your job & employer plan for the full 30 months  Provide the level of care to keep you out of the hospital & help you live longer & better 15

16.  Your clinic should have contact numbers posted:  ESRD Network www.esrdncc.org (map)  ESRD State Survey Agency www.medicare.gov (see contacts)  Fact sheet on how to file a complaint about dialysis care: www.medicare.gov/Publications/Pubs/pdf/11314.pdf 16

17.  The interdisciplinary team must assist the patient in achieving and sustaining an appropriate level of productive activity, as desired by the patient… 42 CFR 494.90(a)(8)  One test of the bundle will be whether it aids or detracts from patients feeling well enough to achieve their goals 17

18.  See if your question has already been asked and answered in the Frequently Asked Questions (FAQs): www.cms.gov/ESRDPayment  If not, send an email with your question to: ESRDPPSFacilityQuestions@cms.hhs.gov 18