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ESRD Injustices in the Medicare World

Updated: Apr 12, 2022

It was just over a year ago that Medicare Advantage Plans finally started allowing people with End Stage Renal Disease (kidney failure on dialysis) to join, thanks to new regulations established by CMS. As agents and advocates for Medicare recipients, we rejoiced. The health insurance companies....not so much. But why?

Dialysis, a benefit which falls under Part B of Medicare, happens to be incredibly expensive. The Part D medications that ESRD patients use can also be outrageously priced. I have seen bills relating to kidney failure that, prior to the insurance company paying their portion, amounted to over $100,000 in a three-month period. No doubt, this is a lot of financial risk for an insurance company to take on.

Regardless, ESRD recipients deserve medical equality. Agents have an ethical duty to the client, which means they should never get caught in the middle. Insurance companies have an obligation to do right by their members and their agents.

I love insurance. I've seen it help so many people. For the most part, I believe that insurance companies mean well, despite their inefficiencies. However, there are discussions that happen behind closed doors that shouldn't be taking place at all. Usually these center around ways to improve the company's bottom line. Sometimes agents are stuck between a rock and a hard place trying to do the right thing for members and not be red-flagged by insurance companies they are contracted with. It's a tough place to be.

Here are examples that I've experienced first-hand:

  1. Previously I worked for a large health insurance company. As I explained, taking on members with high medical costs doesn't benefit an insurance company's bottom dollar. At this company, I experienced (and reported) more than one instance of diverting ESRD clients from their plans to other carriers. In one instance, the company knew that they were going to discontinue a Medicare Advantage plan, and the ESRD members on that plan would need to select a new one. Naturally, they didn't want those high-cost clients in the other plan. The instruction that came down to local agents was to stop enrolling ESRD patients in the plan, even though it was mid-year and this practice is strictly prohibited by Medicare. Once that Medicare Advantage plan did end, it allowed all of those members to join a Medicare Supplement without underwriting. Again the insurer did not want folks on dialysis to join their supplement. The guidance was to put them on another carrier's supplement. I don't know if this is illegal, but it's definitely unethical and detrimental to a competitor's bottom line.

  2. I was recently told that we could contract with a Medicare Supplement provider that had tremendous rates for clients and paid great commissions to the agents. The problem? I was forewarned that if I wrote bad business (meaning high-claims clients) that my contract with the carrier would be terminated. Likewise, when Colorado had the Guaranteed Issue period in 2021 for people to move from Plan F to Plan G, many agents assisted their members in switching. This was great service to the member, but there was at least one insurance company that termed contracts of several agents, because the clients who were moved to their plans had expensive claims.

  3. Here's another new trend that is making life difficult for agents and ESRD patients. Many folks on dialysis receive assistance from the Kidney Fund to pay their monthly supplement premiums. The Kidney Fund is considered a third-party payor. Guess what? Insurance companies have figured out that third-party payors often pay premiums of high-claims clients. The solution? They are no longer accepting third-party payment. There is a work-around, of course. But it's complex and time-consuming, which are criteria that are difficult to meet when you're going to the dialysis center three times per week for exhausting treatments. Shame on the "savvy" insurance companies that are basically pushing sicker individuals to the supplement companies who are operating ethically or haven't yet figured out the sly way of legally refusing ESRD patients to join their plans.

Have you experienced medical discrimination?

The Colorado Gerontological Society, local Areas on Aging, and SHIP offices advocate for seniors as well as providing guidance and assistance. Both are good beginning points to discuss options with if you feel you were discriminated against due to health or disability. I also recommend reaching out to your congressman and urging them to address these inequities.

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