Clarification and application of policy providing for coverage of concurrent palliative dialysis services and hospice care to individuals electing hospice care

(a)

In general

Section 1812(d)(2)(A) of the Social Security Act (42 U.S.C. 1395d(d)(2)(A)) is amended by inserting , to palliative dialysis services (as defined in section 1881(b)(15)(E)) furnished by a provider of services or renal dialysis facility to a palliative dialysis eligible individual (as defined in such section), after (if not an employee of the hospice program). (b)

Separate payment for palliative dialysis services furnished by providers of services and kidney dialysis facilities

(1)

Payment separate from hospice care bundle

Section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)) is amended by adding at the end the following new paragraph:

(8)In the case of palliative dialysis services (as defined in section 1881(b)(15)(E)) furnished by a provider of services or renal dialysis facility to a palliative dialysis eligible individual (as defined in such section) during a period of an election under section 1812(d)(1) made by such individual, the provider of services or renal dialysis facility shall bill and be paid for such dialysis in accordance with section 1881(b)(15).

(2)

Payment methodology

Section 1881(b) of the Social Security Act (42 U.S.C. 1395r(b)) is amended by adding at the end the following new paragraph:

(15)

Payment for palliative dialysis services furnished to individuals electing hospice care

(A)

In general

For 2026 and each subsequent year, the Secretary shall, taking into account the assessment and considerations described in subparagraph (B) and pursuant to rulemaking, establish a methodology for determining, with respect to a palliative dialysis eligible individual whose election under section 1812(d)(1) to receive hospice care is for a period occurring during such year, the payment amounts under this title for palliative dialysis services furnished by a provider of services or renal dialysis facility during such period to such individual in a facility or to such individual at home. (B)

Considerations

In implementing the methodology under subparagraph (A), the Secretary shall— (i)consider calculating payment amounts for such services based on the amounts that would otherwise be calculated under the system established under paragraph (14) for comparable renal dialysis services described in such paragraph; and (ii)consider, after assessing the resources directly or indirectly related to furnishing palliative dialysis services necessary for providers of services and renal dialysis facilities to furnish palliative dialysis services to palliative dialysis eligible individuals in a facility or to such individuals at home, any adjustments that should be applied in calculating such payments amounts based on such assessment. (C)

Limitations

(i)

In general

Subject to clause (ii), payment may not be made under this title for more than ten sessions of palliative dialysis services furnished to a palliative dialysis eligible individual. In the case of home dialysis, including peritoneal dialysis, this subparagraph shall be applied by converting the number of days of such dialysis to hemodialysis equivalent sessions, in accordance with the methodology specified in section 50 of Chapter 11 of the Medicare Benefit Policy Manual, or any successor to such section. (ii)

Secretarial authority to modify limitation

(I)

Assessment and determination

For 2029 the Secretary shall (and for any subsequent year, the Secretary may) pursuant to rulemaking— (aa)assess the appropriateness of the limitation specified under clause (i) for such year, based on data on determinations regarding coverage of palliative dialysis services furnished to palliative dialysis eligible individuals pursuant to this paragraph and stakeholder feedback on such coverage; and (bb)based on such assessment, determine for such year whether to apply a limit on the number of sessions of palliative dialysis services (other than the number specified under clause (i)) and, if so, specify such other number that is to be applied for such year. (II)

Application of modified number limit

For any year for which the Secretary specifies a number pursuant to subclause (I)(bb) other than the number specified in clause (i), clause (i) shall be applied as if the reference to ten sessions were a reference to such different number of treatments specified by the Secretary. (D)

Cost-sharing

Under the methodology under subparagraph (A), the deductible and coinsurance provisions under this title that would apply with respect to kidney dialysis services for which payment may be made under this section (other than this paragraph) shall also apply with respect to palliative dialysis services furnished to a palliative dialysis eligible individual for which payment is made pursuant to this paragraph. (E)

Palliative dialysis services and palliative dialysis eligible individual defined

For purposes of this paragraph: (i)

Palliative dialysis services

The term palliative dialysis services means, with respect to a palliative dialysis eligible individual, dialysis services specified by the Secretary that are furnished to the individual (in a facility or at home) as palliative care, and not for purposes of treatment or maintenance, in accordance with a plan of care certified by the individual’s physician in consultation with the interdisciplinary group described in section 1861(dd)(2)(B), and which may include other services specified by the Secretary, such as non-emergency transportation for which payment would otherwise be available under this section in connection with receipt of maintenance dialysis services. (ii)

Palliative dialysis eligible individual

The term palliative dialysis eligible individual means an individual with end-stage renal disease who makes an election under section 1812(d)(1) and who as of the date of such election was receiving renal dialysis services (as described in section 1881(b)(14)(B)). (F)

Clarification

None of the provisions of this paragraph shall affect coverage or payment under this title which would otherwise apply for renal dialysis services for treatment or maintenance for individuals with end-stage renal disease who make an election for hospice care under section 1812(d)(1) on the basis of a primary health condition other than a terminal condition that is not related to end-stage renal disease.