In a 7-2 decision, the US Supreme Court made it difficult to prove that a health plan violates Medicare secondary payer rules when the plan requires patients to pay out-of-pocket costs for kidney failure treatment with dialysis, when patients switch exclusively to Medicare coverage, regardless Regardless of age, dialysis can be covered at a lower cost to them.
In the dispute over health insurance payments for outpatient dialysis, on June 21, the Supreme Court approved a self-insured health plan in
Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc., rejecting a claim by DaVita Inc. Ltd., one of the largest dialysis providers in the country, found that low health care plan reimbursement rates violate federal law.
Judge Brett Kavanaugh, author of the majority opinion, was joined by Chief Justice John Roberts and Justices Clarence Thomas, Stephen Breyer and Samuel Alito. In the event of dissent, Justice Sonia Sotomayor is joined by Justice Ilana Kagan.
Who pays for dialysis?
DaVita, part of the Optum division of the UnitedHealth Group, argued that the Marietta Memorial Hospital employee health benefits plan in Marietta, Ohio, violated the Medicare Secondary Payment Act (MSPA) by treating all dialysis providers as out-of-network and reimbursing them. them at the lowest rate. MSPA requires special health plans that cover dialysis to be the primary payer for those treatments for at least 30 months after a patient is diagnosed with kidney failure, with Medicare as a secondary payer for Medicare-enrolled patients.
DaVita argued that the lack of any dialysis provider within the network, along with the fact that nearly all patients with end-stage kidney disease (ESRD) who need dialysis are eligible for Medicare regardless of age, encouraged plan participants with ESRD End stage renal failure to drop employer-sponsored coverage and only choose to participate in Medicare to avoid co-pays, coinsurance, and deductibles for dialysis care.
According to Kathryn Heptig, an attorney at Rivkin Radler in Uniondale, NY, MSPA “requires Medicare to be the secondary driver for treating ESRD patients.” [and] prohibits plans from discriminating between ESRD plan participants and other plan participants,” she wrote when the Supreme Court agreed to hear the case.
Not violating the rules of secondary motivation
DaVita’s initial lawsuit was dismissed by a district court judge but then returned by the US Court of Appeals for the Sixth Circuit, which ruled that the plan violated MSPA by discriminating against ESRD patients.
The Supreme Court overturned the Sixth Circuit’s decision and reconsidered the case in line with the Supreme Court’s ruling.
Kavanaugh writes, “Because Marietta Plan provides the same outpatient dialysis benefits to all plan participants, whether or not a participant is eligible or eligible for Medicare, the plan cannot be said to “take into account” whether participants are eligible or Eligible for Medicare “in a way that MSPA does not allow.
In her opposition, Kagan writes, “The reimbursement limit for outpatient dialysis is actually the reimbursement limit for people with end-stage kidney disease. Thus, a plan for dialysis for unwanted coverage” distinguishes[s] in the benefits it provides between individuals with end-stage renal disease and other individuals “in a manner not permitted under the MSPA.”
As for other relevant federal laws, Heptig said variations in coverage for a disability such as ESRD are allowed under the Americans with Disabilities Act (ADA) if they are “based on risk factors determined by actuarial calculations or experience.” Allowing plan discretion under the ADA, she added, is also consistent with the Employee Retirement Income Security Act, which excludes only “arbitrary and volatile” interpretations and enforcement of plans.
Patient advocates, dialysis providers and disillusionment
“Besides the kidney care community, we are very disappointed [the] DaVita CEO Javier Rodriguez said in a statement that the Supreme Court’s decision rescinds an important protection for Americans with chronic kidney failure.
“Hemodialysis patients deserve the best, and we will continue to advocate for patient choice in care and coverage,” he added.
DaVita’s lawyers have warned that a ruling in favor of Marietta’s Memorial Health Plan could open the door to other private health plans that reduce payments for expensive dialysis treatments, prompting more ESRD patients to switch to Medicare, Reuters reported.
Chronic Kidney Patients Advocacy Group, an advocacy group for dialysis patients, released a statement saying it would seek action from Congress to “reform a law that the court has violated.”
But Fresenius Medical Care, one of the country’s largest providers of dialysis services, said in a statement that it “does not expect this case to lead to a significant change in the relationship between providers and health insurers, as the vast majority of those in the industry are concerned.” on the well-being of the sick.”
Reuters also reported that John Kolevich, Marietta’s plan’s attorney, thanked the court “for the careful reading it gave the Medicare Secondary Care Payer Act.”