Table 2.

Key legislation affecting payment for the US ESRD Program

YearPublic LawTitleMajor Provisions
197292–603Social Security Act of 1972Medicare coverage of patients with ESRD <65 yr of age after a 3-mo waiting period
197895–292ESRD Program Amendments of 1978Elimination of the 3-mo waiting period for home dialysis or transplantation
198197–35Omnibus Reconciliation ActEstablishment of single prospective rate to cover all services and supplies for dialysis (composite rate); excluded certain laboratory tests and drugs that were separately billable; MSP for 12 mo after the patient qualifies for Medicare if that patient has employer group health insurance
198699–509Omnibus Reconciliation ActMandatory $0.50 withhold per treatment to fund ESRD Networks
1991MSP increased to 18 mo
2003108–173MMAStatutorily mandated increases in composite rate to adjust for inflation; separately billable drugs reimbursed at average sales price plus 6% (rather than average wholesale cost); composite rate add on to replace drug margins; MSP increased to 30 mo; case-mix adjustment for age and body size
2008110–275MIPPAEstablished bundled reimbursement to include composite rate items and services, injectable drugs and their oral equivalents, and laboratory tests to begin in 2011; oral-only ESRD drugs to be included in the bundle in 2014; new case-mix adjusters; elimination of higher payment for hospital-based providers; Quality Incentive Program to begin in 2012
2012112–240ATRAMandated rebasing of dialysis reimbursement to reflect lower use of drugs; oral-only ESRD drugs to be included in the bundle in 2016
2014113–93PAMASpreads out and reduces rebasing reimbursement cut; oral-only drugs to be included in the bundle in 2024
  • MMA, Medicare Modernization Act; MIPPA, Medicare Improvements for Patients and Providers Act; American Taxpayer Relief Act; PAMA, Protecting Access to Medicare Act of 2014; MSP, Medicare to be secondary payer.