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1 1 (September 14, 2022)

handle is hein.crs/goveiup0001 and id is 1 raw text is: Congressional_______ ~ Research Service Supreme Court Allows Health Plans to Limit Dialysis Benefits September 14, 2022 This past term, the Supreme Court issued a variety of impactful decisions in the health care arena, including some that affect coverage and reimbursement for health care services under federal programs, such as Medicare and Medicaid. Among these decisions is Marietta Memorial Hospital Employee Benefit Plan v. Daita, a case about the intersection of Medicare and employment-based health benefits for patients with end-stage renal disease (ESRD). In DaVita, the Court held that an employer-sponsored health plan could limit benefits for kidney dialysis services without running afoul of the Medicare Secondary Payer (MSP) statute, a provision designed to reduce Medicare spending by moving health care costs from the Medicare program to private payment sources. This Legal Sidebar provides background on the MSP statute, discusses the Court's decision in DaVita, and concludes with selected legal considerations for Congress. Background Medicare is a federal health care program that provides benefits to persons age 65 and older and other qualified beneficiaries, including eligible individuals with ESRD. ESRD is a medical condition involving permanent cessation of kidney function. Patients with ESRD must receive routine dialysis treatment or a kidney transplant to survive. Health care costs for ESRD patients are high. Recent reports estimate that Medicare annually spends approximately $51 billion on ESRD-related treatment. Typically, Medicare is the default primary payer for an eligible beneficiary's covered medical expenses, even when a beneficiary has an additional form of health insurance. Under the MSP statute, however, there are conditions in which payment responsibility shifts to another insurance plan or program and Medicare becomes a back-up, secondary payer, thereby reducing Medicare expenditures. Under the MSP statute, Medicare is a secondary payer to employment-based health plans during a 30-month coordination period. However, federal law does not prevent Medicare-eligible individuals from terminating their employment-sponsored coverage, enrolling in Medicare, and receiving benefits through the program rather than through their employer (although Medicare coverage may not begin immediately). Most relevant to the DaVita case, the MSP statute includes two provisions aimed at preventing employers from transferring ESRD-related treatment costs to the Medicare program: Congressional Research Service https://crsreports.congress.gov LSB10819 CRS Legal Sidebar Prepared for Members and Committees of Congress

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