MEDICAID REIMBURSEMENT AND COVERED SERVICES

• Rates. Although Medicare is by far the dominant payor for dialysis, up to 40 percent of dialysis patients are dual eligible. Medicaid also may be the primary payor for its beneficiaries for 90 days before Medicare coverage begins, and for approximately 10 percent of patients, Medicaid is the only source of coverage for dialysis costs. Medicaid reimbursement for dialysis in most states is well below the average Medicare rate. Because state reimbursement lags behind the cost of care, Medicaid patients run the risk of access problems.
• Managed care. As states integrate managed care into their coverage of chronically ill populations, appropriate risk adjustment will be an important component of rate setting. Dialysis costs must be accurately reflected in rate setting assumptions.
• Benefits. Medicaid benefits such as funding for transportation to dialysis centers are important components of the overall care of dialysis patients and should be maintained and adequately funded. Dialysis patients typically are dependent on a number of prescription drugs and are therefore vulnerable to high out-of-pocket costs. In designing wrap-around benefits and cost-sharing packages for dialysis patients, Medicaid programs should be sensitive to the fragile physical and financial health of dialysis patients and aware of the still higher costs that result from complications if treatment regiments are not strictly maintained.