Medicaid Dialysis Cost Effectiveness Study 2022

Cost Effective and
Clinically Appropriate
Methods to Deliver
Dialysis Services in the
Medicaid Program
As Required by
2022-23 General Appropriations Act,
Senate Bill 1, 87th Legislature,
Regular Session, 2021 (Article II,
Health and Human Services, Rider 35)
Texas Health and Human Services

December 2022
Table of Contents
Introduction ................................................................................................ 3
Background ................................................................................................. 5
Overview of Chronic Kidney Disease in the United States ................................ 6
Overview of End-Stage Renal Disease in Texas ............................................ 10
How Dialysis Services are Covered in Texas ................................................ 12
Cost Effective Dialysis in Texas Medicaid .................................................. 20

Medicare End-Stage Renal Disease Treatment Choices Model ......................... 20
Value-Based Purchasing Models for Dialysis Services .................................... 23
Innovative Delivery Models ...................................................................... 25
Alternatives to Providing Dialysis via Emergency Medicaid ............................. 27
Medicaid Programs from Other States ........................................................ 29
Conclusion ................................................................................................ 32
List of Acronyms ....................................................................................... 33
References ................................................................................................ 34
Appendix A. Referenced Resources ............................................................. 1
Appendix B. Types of Dialysis ..................................................................... 1
Appendix C. Texas Medicaid Inpatient and Outpatient – Professional

Utilization of Renal Dialysis Services, State Fiscal Year 2018-2021,
Medicaid Total ............................................................................................. 1
Appendix D. Texas Medicaid Inpatient and Outpatient – Professional

Utilization of Renal Dialysis Services, State Fiscal Year 2018-2021,
Emergency Medicaid (TP30)........................................................................ 1
ii
Introduction
The 2022-23 General Appropriations Act, Article II, Health and Human Services
Commission (HHSC) Rider 35 (Senate Bill (S.B.) 1, 87th Legislature, Regular
Session, 2021), requires HHSC to study the most cost effective and clinically
appropriate methods to deliver dialysis services through the Medicaid program. This
report was developed in consultation with internal and external stakeholders,
including the Chronic Kidney Disease Taskforce, the Texas Diabetes Council, and
the Department of State Health Services. This report reviews:
● The Medicare End-Stage Renal Disease Treatment Choices model and

whether savings could be achieved through increased utilization of home
dialysis,
● Value-based purchasing models for dialysis services,
● Innovative models of delivering services to persons with renal disease,
including those developed under the Delivery System Reform Incentive
Payment (DSRIP) Program,
● Alternatives to providing dialysis to persons under emergency Medicaid to

improve cost effectiveness and quality and reduce hospitalizations, and
● How other states have modified their Medicaid programs to increase options
in providing dialysis.
Patients living with kidneys that do not function sufficiently may be diagnosed with
chronic kidney disease (CKD) which can progress to end-stage renal disease
(ESRD). Ten percent of the nation’s population of patients living with ESRD reside
in Texas. Routine dialysis therapy is needed to remove toxins and waste byproducts
in the blood. Dialysis treatments are mostly delivered in a hospital or dialysis clinic
setting. Dialysis can also be performed in the home and patients can choose a
kidney transplant to treat their disease. Home dialysis and kidney transplant have
been found to reduce costs and improve quality of ESRD patients.
The most effective way to reduce costs related to CKD and ESRD is by slowing
disease progression. Reducing the number of people who progress from precursor
conditions such as diabetes and high blood pressure will lead to an overall cost
savings in managing kidney conditions. Those who do require chronic dialysis
should be managed with routine dialysis. Preventing delays in treatment can reduce
or eliminate the need for costly emergency dialysis sessions and inpatient hospital
admissions.
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Revised: 12/2022
Medicaid, Medicare, and the Kidney Health program provide coverage for ESRD and
dialysis in Texas. Each program has different eligibility requirements. Texas
Medicaid’s coverage of renal dialysis services includes inpatient services and all
items and services used to furnish outpatient dialysis in an ESRD facility or in a
patient’s home. Patients who are not eligible for these programs may be eligible to
receive financial help through their local hospital district if one is established where
they reside. Hospital district programs offer free or discounted dialysis services to
patients who apply and meet eligibility requirements for these programs.
This report covers dialysis service access, current and past dialysis-focused
programs and projects, alternatives to emergency Medicaid utilization, and a review
of dialysis service coverage by other states.
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Revised: 12/2022
Background
Damage from acute or chronic medical conditions, most commonly diabetes and
high blood pressure, can impair kidney function, resulting in CKD. As the kidneys
lose their ability to effectively remove toxins and waste byproducts in the blood,
CKD can progress to ESRD, which requires routine dialysis therapy as often as
multiple treatments per week.
CKD and ESRD patients can live many years with appropriate dialysis services or
kidney transplant. Various methods of dialysis treatment can be performed in a
dialysis center, hospital, or in the home, as determined by the treating physician in
consideration of patient preference and clinical appropriateness. Patients who delay
receiving required dialysis treatment can become acutely ill, often requiring
emergency services or hospitalization, and are at high risk of end-organ damage
and death.
Recent treatment models encourage dialysis treatment in the home setting to

reduce costs or improve quality of life. Also, kidney transplant is now recommended
earlier in care to improve quality of life by avoiding the prolonged need for dialysis.
Connecting people with preventive services to manage precursor conditions can

slow or inhibit chronic disease development, which is the most effective way to
reduce chronic disease related costs.a Effective management of diabetes and high
blood pressure can prevent progression to CKD and ESRD, reducing the need for
dialysisb and resulting in overall cost savings.c
a
National Center for Chronic Disease Prevention and Health Promotion. (2022). Health and
economic costs of chronic diseases. Retrieved from
https://www.cdc.gov/chronicdisease/about/costs/index.htm
b
Colwell, J. (2021). Getting dialysis for undocumented patients. ACP Internist.
https://acpinternist.org/archives/2021/02/getting-dialysis-for-undocumented-patients.htm
c
Mody, S.H. (2004). Reducing the economic and clinical burden of CKD in the managed care
setting. Biotechnology Healthcare, 1(5), 56-61.
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Overview of Chronic Kidney Disease in the
United States
According to the Centers for Disease Control and Prevention (CDC), chronic kidney
disease is one of the most common chronic diseases in the United States (U.S.).d
The two most common causes of CKD are high blood pressure (hypertension) and
diabetes, but can also be caused by physical injury, disease, or other disorderse.
Prevention is possible by modifying lifestyle factors such as smoking cessation,
consuming a healthy diet, physical activity, and limiting alcohol use.f
The severity of disease progression and illness is categorized by staging

methodology based on how well the kidneys are clearing waste from the blood.
When lab values meet certain established criteria that demonstrate the kidneys are
failing, a patient can be considered to have CKD. With or without treatment CKD
can progress to end-stage renal disease (ESRD), which is permanent kidney failure
that requires a regular course of dialysis or a kidney transplant.
In 2018, almost fifteen percent of adults in the U.S. had lab values that indicate
some level of impaired kidney functioning and possibly CKD or ESRD. CKD is
categorized into stages which indicate the level of functioning, or lack thereof, of
the kidneys. Stage 1 indicates mild kidney damage with function near normal.
Stage 2 indicates mild kidney damage and function near normal. Stage 3a indicates
mild to moderate kidney damage and impaired functioning. Stage 3b indicates
moderate to severe kidney damage. Stage 4 indicates severe kidney damage with
minimal kidney function. Stage 5 is the most severe stage with little to no
functionality in the kidneys.g Table 1 shows the percent of adults in the U.S. who
had CKD between 2015-2018 according to stage as reported in the United States
Renal Data System’s Annual Data Report.
d
National Center for Chronic Disease Prevention and Health Promotion. (2022, May 6).
Chronic diseases in America. Retrieved from
https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
e
National Kidney Foundation. (n.d.). What is kidney failure?
https://www.kidney.org/atoz/content/KidneyFailure?msclkid=f66873b4d16511ec8c580bbf0
1542447
f
Mody, S.H. (2004). Reducing the economic and clinical burden of CKD in the managed care
setting. Biotechnology Healthcare, 1(5), 56-61.
g
American Kidney Fund. (n.d.) Stages of kidney disease. Retrieved from
https://www.kidneyfund.org/all-about-kidneys/stages-kidney-disease
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Revised: 12/2022
Table 1. Prevalence of CKD by stage, 2015-2018
Group Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 All Stages
U.S. Adults 4.7% 3.3% 6.4% 0.4% 0.1% 14.9%
with CKD
Table 2 shows the proportion of adults living with CKD by race in the United States.
White, non-Hispanics have the majority of adults in stage 3 CKD whereas African-
American/Black, non-Hispanics and Hispanic/Latinos have the majority of adults in
stage 1 CKD. The African-American/Black, non-Hispanic racial group also has a
higher amount of adults with CKD who are considered in stage 3 CKD than other
racial groups.
Table 2. Prevalence of CKD by stage, 2015-2018

Racial Group Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
White, Non- 3.8% 3.5% 8.0% 0.3% 0.1%
Hispanic
African 5.9% 3.7% 5.4% 0.7% 0.3%
American/Black,
Non-Hispanic
Hispanic/Latino 6.8% 2.15 2.6% 0.3% 0.1%
Table 3 shows income levels and insurance coverage of adults living with CKD. The
table shows relatively stable data for the past four data collection periods, which
spans fifteen years. The notable changes include the decrease in prevalence of
health insurance types of adults living with CKD who are covered by Medicare,
Medicare and private insurance, and Medicaid. Also, the prevalence of adults living
with CKD whose family income is below the poverty level has increased.
Table 3a. Prevalence of CKD (%) by health insurance coverage, 2003-2018

Health Insurance Coverage 2003-2006 2007-2010 2011-2014 2015-2018
Not Insured 9.9% 7.7% 10.8% 11.1%
Insured 16.8% 14.8% 15.7% 15.5%
Table 3b. Prevalence of CKD (%) by health insurance type, 2003-2018

Health Insurance Type 2003-2006 2007-2010 2011-2014 2015-2018
Private 13.7% 12.3% 13.0% 13.3%
Medicare 43.5% 39.8% 37.5% 36.0%
Medicare + Private 46.9% 40.1% 36.9% 38.0%
Medicaid 25.0% 19.5% 20.9% 16.8%
Military 25.2% 20.2% 17.6% 23.9%
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Table 3c. Prevalence of CKD (%) by family income/poverty ratio, 2003-2018
Family Income/Poverty
Ratio 2003-2006 2007-2010 2011-2014 2015-2018
<1 15.2% 14.5% 17.5% 17.4%
>1 14.5% 13.1% 14.2% 14.4%
Table 4 includes information on risk factors for CKD which are important to assess
as they demonstrate opportunities in disease prevention and mitigation. This table
shows almost seventy-two percent of adults with a diagnosis of CKD had a history
of hypertension (HTN). Diabetes Mellitus (DM) was present in both adults with and
without a diagnosis of CKD, though poorly controlled diabetes, as evidenced by the
higher percentage of glycosylated hemoglobin, a test that measures the amount of
sugar in the blood, had higher prevalence in the CKD population. Lastly, LDL
cholesterol, also known as bad cholesterol, was similarly present in both
populations of adults with and without CKD.
Table 4a. Prevalence of CKD Risk Factor: Hypertension, % of U.S. Adult Population,
2015-2018
Hypertension CKD No CKD
No 28.2% 72.4%
Yes 71.8% 27.6%
Table 4b. Prevalence of CKD Risk Factor: Diabetes, % of U.S. Adult Population,
2015-2018
Diabetes (Glycosylated
Hemoglobin) CKD No CKD
<7% 43.0% 53.9%
7-7.9% 26.0% 25.5%
>8% 31.0% 20.7%
Table 4c. Prevalence of CKD Risk Factor: LDL Cholesterol, % of U.S. Adult
Population, 2015-2018
LDL Cholesterol CKD No CKD
<70 mg/dL 11.0% 8.9%
70-99 mg/dL 27.4% 29.3%
≥100 mg/dL 61.6% 61.8%
Table 5 includes information specific to Medicare beneficiaries over the age of sixty-
six years with a diagnosis of CKD stratified by their risk factors of diabetes and
hypertension. Most adults in this category had both diabetes and hypertension.
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Revised: 12/2022
Prevalence of these risk factors rose with age. Examining risk factors by race and
ethnicity shows white adults in this population had the highest rate of neither
diabetes nor hypertension, although this was low compared to the other risk factor
categories. Black adults in this population had the highest rate of hypertension as
their only risk factor and having both diabetes and hypertension as risk factors.
Asian adults in this population had the highest rate of diabetes as their only risk
factor.
Table 5a. Prevalence of CKD (%), by presence of diabetes mellitus and

hypertension in Medicare beneficiaries aged ≥66 years, overall, 2018
Neither DM nor
Group HTN HTN Only DM Only HTN and DM
Overall 2.1% 15.0% 10.0% 31.0%
Table 5b. Prevalence of CKD (%), by presence of diabetes mellitus and

hypertension in Medicare beneficiaries aged ≥66 years, by age range, 2018
Neither DM nor
Age Range HTN HTN Only DM Only HTN and DM
66-69 1.2% 8.3% 7.1% 22.4%
70-74 1.7% 10.6% 8.1% 27.2%
75-79 2.4% 14.4% 10.5% 32.1%
80-84 3.5% 18.6% 14.1% 37.2%
85+ 4.9% 24.9% 17.5% 42.1%
Table 5c. Prevalence of CKD (%), by presence of diabetes mellitus and

hypertension in Medicare beneficiaries aged ≥66 years, by gender, 2018
Neither DM nor
Gender HTN HTN Only DM Only HTN and DM
Male 2.2% 16.4% 10.6% 33.0%
Female 2.0% 13.9% 9.4% 29.2%
Table 5d. Prevalence of CKD (%), by presence of diabetes mellitus and

hypertension in Medicare beneficiaries aged ≥66 years, by race/ethnicity, 2018
Neither DM nor
Race/Ethnicity HTN HTN Only DM Only HTN and DM
White 2.2% 14.8% 10.2% 30.9%
Black 1.4% 18.7% 8.8% 34.1%
Native American 1.3% 13.1% 8.8% 29.4%
Asian 1.5% 14.7% 11.1% 30.3%
Hispanic 1.2% 14.5% 6.7% 28.9%
Other/Unknown 1.4% 9.6% 7.7% 25.1%
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Revised: 12/2022
Comorbid conditions associated with CKD include atherosclerotic heart disease
(ASHD), heart failure (HF) and diabetes (DM). Among fee-for-service Medicare
beneficiaries aged 66 years or older in 2018, 71.1 percent of those with CKD had
one or more of these three comorbid conditions, compared with only 32.4 percent
of those without. DM, which occurred in approximately half of individuals with CKD,
was roughly 2.5 times as common in patients with CKD compared with those
without. This was the same for ASHD. HF was approximately 4.4 times as common
among those with CKD.
Health care expenditures are higher for all people living with chronic conditions. For
adults enrolled in fee-for-service (FFS) Medicare, those with CKD who did not have
ESRD represented twenty-three percent of total Medicare FFS expenditures.h Health
care utilization is also higher for the CKD population. All-cause hospitalization rate
(adjusted, 2019) was about two point four times higher for Medicare FFS adults
living with CKD compared to adults without CKD. Medicare Advantage adults living
with CKD saw similar all-cause hospitalization rates. Mortality from CKD has
declined over the past ten years due to advancements in care for people with CKD
as well as changes in the detection of the disease. The mortality rate for Medicare
adults with a diagnosis of CKD remained about twice that of Medicare adults
without CKD.
Overview of End-Stage Renal Disease in

Texas
Alliant Health Solutions is the Quality Innovation Network-Quality Improvement
Organization (QIN-QIO) serving Texas. They assess ESRD statistics in Texas, which
is referred to as Network 14. In 2021, the QIN-QIO counted 75,738 unique ESRD
patients in Network 14 who had received dialysis or a kidney transplant.i Ten
percent of the national population of patients living with ESRD reside in Network
14. Texas has the largest percentage of ESRD patients of all the networks serviced
by this QIN-QIOj.
h
United States Renal Data System. (2020). USRDS Annual Data Report: Epidemiology of
kidney disease in the United States. National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2021.
i
Alliant ESRD Network 14. (2022). 2021 Annual Report. Retrieved from
https://quality.allianthealth.org/media_library/esrd-nw14-2021-annual-report/
j
The QIN-QIO serves the following networks: Alabama, Florida, Georgia, Kentucky,
Louisiana, North Carolina, Tennessee, and Texas.
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Revised: 12/2022
Figure 1. Count of Prevalent ESRD Patients by Treatment Setting, Texas (Network
14)
To care for these patients, Texas (Network 14) has 783 dialysis facilities.k Almost
three-quarters of these dialysis facilities are managed by large dialysis
organizations and the rest are small organizations or independent practices. Sixty-
one percent of patients receive dialysis services in a dialysis center. Ten percent of
patients use home dialysis modalities. Twenty-nine percent of patients are living
with a kidney transplant.l
Data from the Advancing American Kidney Health report published by the U.S.
Health and Human Services shows the prevalence of ESRD by state. The map below
shows prevalence rates of ESRD per one million people. The darker the shading on
the map, the higher the prevalence rate. Texas is in the second highest prevalence
rate category.
k
l
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Revised: 12/2022
Figure 2. Prevalence of ESRD by U.S. State for 2016
How Dialysis Services are Covered in Texas
Medicaid
Texas residents who are determined eligible for Medicaid can receive dialysis
services. Medicaid eligibility requirements include:
● Live in and intend to remain in Texas

● Be a United States citizen or meet immigration status requirements
● Financial eligibility requirements, which vary by each Medicaid program,
defined as a percentage of the federal poverty level (FPL).
● Meet a Medicaid eligibility category, such as pregnant women, children,
certain parents/caretakers, people with disabilities, and/or elderly.
Information on these programs and the eligibility process can be found in the 13th
Edition Texas Medicaid and CHIP Reference Guide.
Texas Medicaid’s coverage of renal dialysis services includes all items and services
used to provide outpatient maintenance dialysis in an ESRD facility or in a patient’s
home when medically necessary. Renal dialysis services include:
● All items and services included under the composite rate
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Revised: 12/2022
● Injectable drugs and biologicals and their oral or other forms of
administration that are for the treatment of ESRD
● Diagnostic laboratory tests that are for the treatment of ESRD
● Home and self-dialysis training, and
● All supplies, equipment, and self-dialysis support services necessary for the
effective performance of a patient’s dialysis provided in the ESRD facility or
in a patient’s home. Support services may include dialysis access sites and
equipment monitoring, blood clots removal, patient referral, and direct
services from registered nurses, licensed vocational nurses, technicians,
social workers, and dietitians.
Texas Medicaid reimburses renal dialysis services on a per-treatment basis for all
client ages. ESRD facilities providing dialysis treatments, whether in center or in
home and regardless of modality, receive payment for up to three hemodialysis
treatments per week, unless there is a medical necessity for a greater frequency.
Under the current policy, renal dialysis services are reimbursed according to
composite rates which align with Medicare prior to 2011. Medicare currently
reimburses for ESRD using a prospective payment system instead of a composite
rate payment. To reduce cost, streamline reimbursement, clarify the ESRD services
benefit, and provide clear direction for billing in-center and home dialysis, HHSC
implemented the following policy updates, effective March 1, 2022:
● Included all Medicare composite rate items and services into Texas Medicaid’s
composite rate
 Renal facilities now receive one payment per session or per day
depending on the treatment modality for all items and services related to
the treatment of ESRD, including routine labs and drugs that were
previously separately reimbursed, to closer align with Medicare’s
methodology.
● Removed Method II composite rate

 Renal facilities must now directly or under arrangement provide home
dialysis clients with all necessary equipment and supplies, maintenance,
and support. Dialysis DME suppliers are no longer reimbursed separately
for equipment and supplies and the renal dialysis facility will not receive
separate reimbursement for support services. The renal dialysis facility
now receives the same payment for home dialysis clients as they would
receive for an in-center dialysis client. If an arrangement is made with a
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Revised: 12/2022
DME supplier, the DME supplier must seek reimbursement from the renal
dialysis facility. Based on utilization data, renal facilities have been billing
Texas Medicaid in alignment with Medicare’s policies for a number of
years so this update is not expected be a significant change for most
providers.
Appendix A of this report includes claims processing details, the prospective

payment system, and billing requirements.
Tables 6a-c show total costs for dialysis services for the Texas Medicaid program for
state fiscal year 2018 through 2021. These costs include inpatient and outpatient
utilization of dialysis services.
In the state fiscal years shown, the number of clients, the amount paid, and the
average amount paid per client has decreased for Medicaid Fee-for-Service. The
number of clients, the amount paid, and the average amount paid per client has
increased in Medicaid Managed Care. For Medicaid Total, the combination of all
programs, the number of clients has decreased in the four-year time frame shown
while the amount paid and average amount paid per client has increased. Appendix
C shows detailed costs associated with providing dialysis services in Texas’ Medicaid
program for state fiscal years 2018-2021. It is unknown if or how the COVID-19
public health emergency has impacted the figures for 2020-2021.
Table 6a. Texas Medicaid Inpatient and Outpatient – Professional Utilization of

Renal Dialysis Services, State Fiscal Year 2018-21, Annual Program Totals for
Medicaid Fee-for-Service (Includes Emergency Medicaid)
Medicaid Fee-for-
Service 2018 2019 2020 2021
Clients 15,504 15,860 14,909 13,394
Amount Paid $4,613,442.46 $4,420,228.72 $4,155,093.93 $3,570,235.53
Average Amount $297.56 $278.70 $278.70 $266.55
Paid per Client
Table 6b. Texas Medicaid Inpatient and Outpatient – Professional Utilization of
Medicaid Managed Care
Medicaid Managed
Care 2018 2019 2020 2021
Clients 5,036 5,245 4,837 5,058
Amount Paid $70,583,049.32 $76,872,838.39 $80,487,298.83 $79,826,119.08
Average Amount $14,015.70 $14,656.40 $16,639.92 $15,782.15
Paid per Client
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Revised: 12/2022
Table 6c. Texas Medicaid Inpatient and Outpatient – Professional Utilization of
Medicaid Total
Medicaid Total 2018 2019 2020 2021
Clients 19,191 19,686 18,532 17,271
Amount Paid $75,196,491.78 $81,293,067.11 $84,642,392.76 $83,396,354.61
Average Amount $3,918.32 $4,129.49 $4,567.36 $4,828.69
Paid per Client
Emergency Medicaid
Certain immigrants may qualify for Emergency Medicaid coverage, if all other
Medicaid eligibility requirements are met except for immigration status. If
determined eligible for Emergency Medicaid, Medicaid only covers care until the
emergency medical condition is stabilized. Emergency Medicaid does not cover
routine dialysis services as this is not considered an emergency medical condition in
the state of Texas.
Table 7 shows total costs (all funds) for the Texas Emergency Medicaid program for
state fiscal year 2018 through 2021 for inpatient and outpatient utilization of
dialysis services. In the state fiscal years shown, the number of clients decreased,
the amount paid remained stable, and the average amount paid per client
increased. Appendix D shows detailed costs associated with providing dialysis
services in Texas’ Emergency Medicaid program for state fiscal years 2018-2021.
Table 7. Texas Medicaid Inpatient and Outpatient – Professional Utilization of

Renal Dialysis Services, State Fiscal Year (FY) 2018-21, Annual Program Totals for
Emergency Medicaidm
Average Amount
State Fiscal Year Clients Amount Paid Paid per Client
2018 514 $351,903.86 $684.64
2019 553 $335,765.67 $607.17
2020 508 $432,220.70 $850.83
2021 377 $358,548.53 $951.06
m
There may be additional costs for inpatient services that are paid for as part of a DRG
payment made to the hospital providing care that are not able to be reflected in these
amounts.
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Revised: 12/2022
Medicare
People of any age with a diagnosis of ESRD may be eligible for Medicare benefits if
they meet one of the below requirements:
● Worked the required amount of time under Social Security, the Railroad
Retirement Board (RRB), or as a government employee
● Are already getting or are eligible for Social Security or RRB benefits
● Are the spouse or dependent child of a person who meets either of the
requirements above
Medicare health insurance coverage is divided into different parts. Original Medicare
includes parts A and B. Applicants can choose to add Part C and/or Part D
depending on what coverage they purchase. The below table defines the different
parts of Medicare.
Table 8. Parts of Medicare
Medicare Partn Description
Part A (Hospital Insurance) Helps cover inpatient care in hospitals, skilled nursing
facility care, hospice care, and home health care
Part B (Medical Insurance) Helps cover services from doctors and other health care
providers, outpatient care, home health care, durable
medical equipment (like wheelchairs, walkers, hospital
beds, and other equipment), and many preventive
services (like screenings, shots or vaccines, and yearly
“Wellness” visits)
n
Medicare.gov (2022). Parts of Medicare. Retrieved from
https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-
medicare
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Revised: 12/2022
Medicare Partn Description
Part C (Medicare Advantage) A Medicare-approved plan from a private company that

offers an alternative to Original Medicare for health and
drug coverage. Plans are usually ‘bundled’ including Part
A, Part B, and usually Part D. Some plans offer extra
benefits that original Medicare does not cover such as
vision, hearing, and dental services.
Part D (Drug coverage) Helps cover the cost of prescription drugs (including many
recommended shots or vaccines) through a Medicare drug
plan in addition to Original Medicare, or a Medicare
Advantage Plan with drug coverage. Plans that offer
Medicare drug coverage are run by private insurance
companies that follow rules set by Medicare.
Dialysis services and supplies are covered by Medicare in both Parts A and B. Part A
includes inpatient dialysis treatment. Part B covers outpatient dialysis treatment,
physician services related to dialysis, home dialysis training, home dialysis
equipment and supplies, certain home support services, most drugs related to
outpatient and home dialysis, and other supplies related to dialysis.
Medicare has a 90-day waiting period that must be fulfilled. Coverage will then
begin in the fourth month of dialysis. People living with ESRD in Texas may be
eligible for the KHC program, as described in this report, to help cover costs during
this waiting period. Details on Medicare coverage of dialysis services can be found
in the Medicare Coverage of Kidney Dialysis & Kidney Transplant Services booklet.
Kidney Health Care Program

The Kidney Health Care (KHC) program provides limited benefits to eligible clients
with ESRD to assist with medical expenses directly resulting from ESRD care and
treatment. Benefits may include medical treatments such as access to surgery and
dialysis treatments, financial assistance with transportation, approved medications,
and the payment of premiums in some instances.
The KHC program was established by the Texas Legislature in 1973 during the 63rd
Texas Legislature, to address gaps in the Medicare Chronic Renal Disease (CRD)
program. Many beneficiaries receive benefits during the Medicare waiting period.
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Revised: 12/2022
The KHC program helps with expenses including treatment and prescription
medication costs not covered by Medicare; costs related to Medicare prescription
drug deductibles, coinsurance amounts, premium payment assistance, Part D Donut
Hole (or Coverage Gap) expenditures; and transportation costs associated with
ESRD treatment. Data for the program is published annually. Appendix A includes
links to the most recent full reports on the KHC program, state fiscal year 2019-
2021.
To be eligible for KHC benefits, an applicant must meet the following criteria:
● Have a diagnosis of ESRD certified by physician;
● Receive regular dialysis treatments or have received a kidney transplant;

● Have a gross income less than $60,000 annually; and
● Be a Texas resident.
Recipients are expected to apply for Medicare. Applicants must not have full
Medicaid (drugs, medical, and transportation benefits) nor be a ward of the state or
be incarcerated in a city, county, state, or federal jail or prison.
Benefits available to KHC clients are dependent on treatment status and eligibility
for benefits from other programs such as Medicare, Medicaid, or private insurance.
KHC is the payer of last resort in that KHC benefits are paid only after all other
third-party payers have met their liability.
KHC is also a State Pharmaceutical Assistance Program (SPAP) for clients diagnosed
with ESRD and who are receiving kidney dialysis or have had a kidney transplant.
An SPAP is a state-administered program certified by the Centers for Medicare and
Medicaid Services to coordinate with Medicare's prescription drug program and
make payments secondary to Medicare that will count toward the individual's out-
of-pocket expenses. All payments made by KHC for drugs covered by Medicare Part
D count towards the clients’ true out-of-pocket (TrOOP) expenses.
KHC clients are designated by their treatment modality, which is based on their
clinical needs and helps to determine benefits they receive. The below table shows
the treatment modality of KHC eligible clients, the percent of clients receiving
dialysis, and the percent of clients in the program by modality for fiscal year 2021.
The majority of clients are receiving dialysis in a facility setting. The next largest
group of clients are those who have received a kidney transplant. The smallest
population of clients receives home dialysis.
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Revised: 12/2022
Table 9. Modality of KHC Eligible Clients Fiscal Year 2021
% %
Dialysis Total
Count Modality Clients Clients
11,270 Facility Dialysis 86% 54%
1,894 Home Dialysis 14% 9%
7,826 Transplant N/A 37%
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Revised: 12/2022
Cost Effective Dialysis in Texas Medicaid
Medicare End-Stage Renal Disease Treatment

Choices Model
Renal dialysis services provided to Medicare beneficiaries are paid for via a bundled
prospective payment system (PPS) as of January 1, 2011. The ESRD PPS provides a
patient-level and facility-level adjusted per treatment (dialysis) payment to ESRD
facilities for renal dialysis services. Services can be provided at the facility or at the
patient’s home. The bundled payment includes the cost of medications, laboratory
testing, supplies, and capital-related costs. Training for home and self-dialysis are
available as add-on as well as additional payment for high-cost outliers.o
CMS instituted the ESRD Treatment Choices (ETC) Model on January 1, 2021. The
model aims to increase the use of home dialysis and kidney transplant for Medicare
beneficiaries living with ESRD to decrease the high costs associated with ESRD and
to improve the quality of care for ESRD patients. “Under the ETC Model, CMS
makes certain payment adjustments that encourage participating ESRD facilities
and managing clinicians to ensure that ESRD beneficiaries have access to and
receive education about their kidney disease treatment options. Specifically, CMS
positively adjusts certain Medicare payments to participating ESRD facilities and
Managing Clinicians for the first three years of the model for home dialysis and
dialysis-related services.”p There are two payment adjustments in the ETC Model:
● A uniformly positive adjustment on Medicare claims for home dialysis during

the initial three years of the model, and
● A per treatment payment adjustment, either upward or downward, for

dialysis based on the rate of home dialysis and transplant rate calculated as
the sum of the transplant waitlist rate and the living donor transplant rate.
o
End Stage Renal Disease (ESRD) Prospective Payment System (PPS). (2021, December
22). Centers for Medicare and Medicaid Services. Retrieved May 10, 2022, from
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment?msclkid=b3b4c57dcfce11eca389aa42fd77d837
p
ESRD Treatment Choices (ETC) Model. (2022, May 9). Centers for Medicare and Medicaid
Services. Retrieved May 9, 2022, from https://innovation.cms.gov/innovation-models/esrd-
treatment-choices-model
20
Revised: 12/2022
The ETC Model also incentivizes providers to address disparities in home dialysis
and transplant rates. Additional improvement points, which are used to determine
incentive amounts, can be earned by participating providers who demonstrate
significant improvement in the home dialysis rates or transplant rates among dual-
eligible beneficiaries or Low Income Subsidy (LIS) recipients in their care. Also,
achievement benchmarks will be stratified by the proportion of beneficiaries who
are dual-eligible beneficiaries or LIS recipients to ensure providers who see a
disproportionately high volume of these patients will not be negatively affected
during benchmark scoring. The innovative model description and additional
resources can be found on the CMS website.
Home Dialysis Cost Effectiveness

HHSC reviewed home dialysis studies that assessed cost effectiveness and cost
outcomes based on modality. There were few studies available that focused
specifically on actual cost changes associated with implementing home dialysis.
Literature reviews, editorials, and an international workshop summary provided
broader views and incorporated compounding factors surrounding home dialysis.
A single-center study from Manitoba, Canada implemented a cost minimization

model by implementing full- and partial-assist home hemodialysis (HD) and
continuous cycling peritoneal dialysis (CCPD) over a one-year time period.q The
outcome metrics of the annual total per-patient costs (maintenance and training)
were presented by modality and whether the patient received full- or partial-assist
services compared to in-center dialysis services. The table below summarizes the
per-patient costs observed at the conclusion of the study. Each modality was
compared to in-center hemodialysis. The study found that all modalities delivered in
the home setting, with the exception of both peritoneal dialysis methods that
required an assistant, realized a cost savings as compared to in-center
hemodialysis. This suggests that encouraging more use of in-home hemodialysis
and peritoneal dialysis methods could result in a cost savings.
q
Bamforth, R.J., Beaudry, A., Ferguson, T.W., Rigatto, C., Tangri, N., Bohm, C., &
Komenda, P. (2021). Costs of assisted home dialysis: A single-payer Canadian model from
Manitoba. Kidney Medicine, 3(6), 942-950. doi: 10.1016/j.xkme.2021.04.019
21
Revised: 12/2022
Table 10. Net Accumulated Costs & Savings Realized at 1 Year by Modality
(Converted to United States Dollars)r
Home CCPD Home HD
In-Center (Partial- Home CCPD (Complete
Modality HD Home CAPD Home CCPD Assist) (Full-Assist) Home HD Care)
1-Year $50,502.51 $31,111.64 $40,001.28 $51,397.52 $56,662.95 $45,580.75 $48,265.50

Cost
Savings N/A $19,390.87 $10,501.23 ($895.01) ($6,160.44) $4,921.77 $2,237.01

Compared
to In-
Center
HD
This study also determined cost-neutrality variables that represented the time in
which a cost savings was realized between modalities compared to in-center
services. For self-administered continuous ambulatory peritoneal dialysis (CAPD), a
cost savings was achieved at 2.94 months. Self-administered CCPD was cost
neutral at 4.76 months with the time point increasing if CCPD was delivered via
partial- or full-assist models. For HD, cost savings was achieved at 7.12 months.
For a patient requiring complete care HD, which includes a health aide who remains
with the patient during HD treatment, a cost-neutral point was recognized at only
0.02 months as compared with in-center dialysis. Overall, the study found that
home-based modalities can offer similar or reduced costs of care per patient.
A second study out of Ontario, Canada reviewed patient data to assess the cost
effects of long-term home-based PD and HD treatmentss. The researchers reviewed
over 12,000 cases of patients older than eighteen years who initiated routine
dialysis for chronic kidney disease. Similar to the prior study, patients were grouped
by modality and mean costs at 30 days were assessed at the five-year mark. The
analysis found that mean costs at thirty-day were lower for patients who received
in-home dialysis treatments as compared to patients who received dialysis in a
facility. Patients who received PD had fifty percent lower thirty-day costs and
patients who received HD had sixty-four percent lower thirty-day costs. The
r
Komenda, P. (2021). Costs of assisted home dialysis: A single-payer Canadian model from
Manitoba. Kidney Medicine, 3(6), 942-950. doi: 10.1016/j.xkme.2021.04.019
Note: Canadian Dollar to U.S. Dollar conversion rate as of November 23, 2022.
s
Krahn, M.D., Bremner, K.E., de Oliveira, D., Dixon, S.N., McFarlane, P., Garg, A.X.,
Mitsakakis, N., Blake, P.G., Harvey, R., & Pechlivanoglou, P. (2019). Home dialysis is
associated with lower costs and better survival than other modalities: A population-based
study in Ontario, Canada. Peritoneal Dialysis International, 39(6), 553–561.
doi:10.3747/pdi.2018.00268
22
Revised: 12/2022
survival rate was also assessed for these populations. Patients who received in-
home dialysis treatments had higher five-year unadjusted survival rates than those
who were dialyzed in a facility. This second study also suggests savings and
increased survival rates for home-based dialysis.
Value-Based Purchasing Models for Dialysis

Services
HHSC is moving away from paying for volume to paying for the value of health care
services. The main avenues pursued by HHSC to move towards value-based care
are the following:
● Managed Care Value-Based Payment Programs,

● 1115 Healthcare Transformation Waiver, and
● Directed Payment Programs.
All of these programs are monitored yearly by examining the trends in key quality
measures used to measure the performance of each individual program.
The transformation to value-based care aims to achieve better care for individuals,
better health for populations, and lower cost for the state. To this end, HHSC has
implemented contract requirements for MCOs to achieve minimum levels of
alternative payment model (APM) agreements with their providers. Calendar year
2018 was the first measurement year for these value-based payment (VBP)
initiatives, and HHSC’s MCOs have met expectations on both initiatives since they
were introduced. The impact of the novel coronavirus (COVID-19) public health
emergency on the entire health care system, including Medicaid and CHIP, led
HHSC to freeze APM level requirements for 2022. An assessment of all the APMs
developed by MCOs and the providers since this program has been introduced did
not find any interventions specifically dedicated to address dialysis services.
HHSC is also actively working to sustain a Texas Medicaid program that continues
to advance value-based care and other effective delivery system reforms as funding
for the Delivery System Reform Incentive Payment (DSRIP) program ends. HHSC
submitted a set of reports to the Centers for Medicare and Medicaid Services (CMS)
addressing each of the milestones in its DSRIP Transition Plan approved by CMS in
2020. The milestone reports lay the groundwork to develop strategies, programs
and policies to sustain successful DSRIP activities and incorporate emerging areas
of innovation into the Medicaid program.
23
Revised: 12/2022
Finally, HHSC monitors hospital Potentially Preventable Complications (PPCs) as
part of its Hospital Quality Based Payment Program. An examination of the trends
of more than 60 PPCs over the previous seven years (of available data), found
“Renal Failure without Dialysis” to be among the five most frequent preventable
complications. As shown (Figure 3), in the first three years of observation it was the
predominant PPC, while in the next four years, it was the third (Figure 4). The two
separate assessment time periods were applied to make the distinction in the
change of the methodology employed to examine the trends of these complications.
Figure 3. Changes in hospital PPC performance for 2014–2016
These trends indicate the need to adopt interventions to reduce complications,

some of which might be through the development of APMs within a larger approach
of value-based care.
24
Revised: 12/2022
Figure 4. Changes in hospital PPC performance for 2017–2020
Innovative Delivery Models
Delivery System Reform Incentive Payment

(DSRIP) Program
In the first several years of the DSRIP Program, participating organizations received
funding for projects they designed to improve the delivery and quality of health
care services. Parkland Hospital created a new outpatient hemodialysis pilot with
Fresenius, a dialysis services company. Overall goals were optimal treatment,
reduced cost of care, and elimination of emergency department (ED) to Acute
Dialysis Unit (ADU) cycles. They identified three tiers of patients:
● Tier 1: Includes the most stable patients with the fewest weekly ED/ADU
visits
● Tier 2: Includes less stable patients with 3 or more weekly ED/ADU visits and
increased rate of psych/social issues
● Tier 3: Includes unstable patients
25
Revised: 12/2022
For patients in Tier 1, the goal was to eliminate the ED to ADU cycles. For patients
in Tier 2, the goal was to reduce the ED to ADU cycles and stabilize the patient
clinically. A goal was not set for patients in Tier 3. The target population for the
interventions was a combination of Tier 1 & Tier 2 patients. The project’s first
intervention was to start a peritoneal dialysis program for Tier 1 patients only. The
second intervention was to launch an outpatient hemodialysis clinic for patients for
whom this was clinically appropriate.
Starting in Demonstration year (DY4) (October 1, 2014), patients were selected to

transition to scheduled outpatient dialysis, rather than acute dialysis through the
emergency department. For DY4, Parkland Hospital’s goal was to serve 394
individuals via the outpatient hemodialysis clinic. The hospital surpassed their goal
and served 424 in the clinic. In DY5 the hospital’s goal was to serve 432 individuals
and the hospital again surpassed this goal and by caring for 465 individuals. For
DY6, the hospital’s goal was set again at 432 and was surpassed for a third time by
caring for 477 individuals.
Parkland Hospital submitted data throughout the project for evaluation of

effectiveness. For fiscal year 2013, the hospital reported the average direct cost per
dialysis patient in the project was $48,734, by fiscal year 2015 the average direct
cost was $42,448, and for fiscal year 2016 the average direct cost per patient was
$37,772. This represents a 22.5 percent decrease in average direct cost per patient
from fiscal year 2013 to fiscal year 2016. This routine dialysis care program model
was able to achieve reductions in the cost of care for the individuals served by the
pilot.
Alternative Models of Care in Texas

Some ESRD patients in the state of Texas receive dialysis services through their
local hospital district. Hospital districts are funded via local taxes imposed on
residents residing in the district’s county, municipality, or other governmental
entity.t Hospital districts are charged with operating hospital facilities and providing
medical and hospital care for the district's needy inhabitants.u The district also
assumes any outstanding indebtedness incurred by a county, municipality, or other
t
Texas Health and Safety Code. Title 4. Health Facilities, Subtitle D. Hospital Districts,
Chapter 286. Hospital Districts Created by Voter Approval, Subchapter A., General
Provisions. Available at https://statutes.capitol.texas.gov/Docs/HS/htm/HS.286.htm
u
26
Revised: 12/2022
governmental entity in which all or part of the district is located in providing
hospital care for residents of the territory.v To receive services, residents of the
hospital district must apply to the district’s health coverage program. For example,
in Travis county, uninsured residents can apply to the Medical Access Program
(MAP) via Central Health.w Bexar county operates a similar program called CareLink
via the University Health System.x Harris county offers a Financial Assistance
Program, via Harris Health System.y Residents who sign up for coverage from one
of these programs make a monthly payment based on total household income and
family size.z Members are able to access dialysis services at dialysis facilities within
the health district.
Specifically for Harris Health Financial Assistance Program members, dialysis

services are provided at Riverside Dialysis Clinic.aa The clinic describes dialysis for
undocumented and uninsured patients, including those who sign up for the financial
assistance program, which requires an appointment.bb Those in need of dialysis are
encouraged to call for an appointment in advance due to limited capacity at the
clinic.cc
Alternatives to Providing Dialysis via

Emergency Medicaid
Title 42 code of federal regulations (CFR) § 440.255 requires states to treat
emergency medical conditions, which are those that, “in the absence of immediate
medical attention, could place a patient’s health in serious jeopardy, cause serious
impairment to bodily functions, or serious dysfunction of any bodily organ or part.”
v
w
“What is MAP and MAP Basic?” (2022). Retrieved from
https://www.centralhealth.net/map/
x
“What is CareLink?” (2022). Retrieved from
https://www.universityhealthsystem.com/patient-visitor-resources/support/carelink
y
“Patient Eligibility”. (n.d.) Retrieved from https://www.harrishealth.org/access-
care/patient-eligibility
z
“CareLink Frequently Asked Questions.” (2022). Retrieved from
https://www.universityhealthsystem.com/patient-visitor-resources/support/carelink/faqs
aa
“Riverside Dialysis Center. (n.d.). Retrieved from https://www.harrishealth.org/locations-
hh/Pages/riverside-dialysis-center.aspx
bb
Bryant, N. (2022). Riverside dialysis clinic: Dialysis in Houston for the uninsured.
Retrieved from https://houstoncasemanagers.com/riverside-clinic/
cc
27
Revised: 12/2022
Each state must define which conditions are included as emergency conditions.
Most states, including Texas, include emergency-only hemodialysis as an
emergency medical condition, but do not cover routine scheduled dialysis.dd
A study from Dallas examined outcomes for undocumented immigrants living with
ESRD who received scheduled dialysis compared to emergency-only dialysis. The
group that received schedule dialysis were enrolled in a private commercial
insurance program provided by the facility. At twelve months, the participants who
received schedule dialysis were found to have lower mortality, fewer emergency
department visits, fewer hospitalizations, and fewer hospital days.ee
In multiple studies analyzing the effects of scheduled dialysis programs, actual

costs decreased and estimated savings increased. One U.S. study estimated
emergency-only dialysis cost to be $285,000-$400,000 per person per year versus
$76,177-$90,971 for standard dialysis services.ff The study from Parkland Hospital
in Dallas, estimated an average savings of $5,768 per member per month.gg In
Colorado the cost estimate for emergency-only dialysis was up to $400,000 per
person per year compared to under $100,000 for scheduled outpatient dialysis,
with a potential savings of over $5,700 per person per month if switched to a
scheduled dialysis model.hh These costs and potential savings are not necessarily
specific to Medicaid programs, but rather to the programs studied that aimed to
decrease the cost of ESRD-related patient care for unfunded patients.
dd
Khullar, D. & Chokshi, D.A. (2019). Immigrant health, value-based care, and emergency
Medicaid reform. Journal of the American Medical Association (JAMA), 321(10), 928-929.
doi: 10.1001/jama.2019.0839
ee
Nguyen, O.K., Vazquez, M.A., & Charles, L. (2019). Association of scheduled vs
emergency-only dialysis with health outcomes and costs in undocumented immigrants with
end-stage renal disease. Journal of the American Medical Association Internal Medicine,
179(2), 175-183. doi: 10.1001/jamainternmed.2018.5866
ff
Rizzolo, K., Novick, T.K., & Cervantes, L. (2020). Dialysis care for undocumented
immigrants with kidney failure in the COVID-19 era: Public health implications and policy
recommendations. American Journal of Kidney Disease, 76(2), 255-257. doi:
10.1053/j.ajkd.2020.05.001
gg
emergency-only dialysis with health outcomes and costs in undocumented immigrants with
end-stage renal disease. Journal of the American Medical Association Internal Medicine,
179(2), 175-183. doi: 10.1001/jamainternmed.2018.5866
hh
https://acpinternist.org/archives/2021/02/getting-dialysis-for-undocumented-patients.htm
28
Revised: 12/2022
Medicaid Programs from Other States
Other states or districts have modified their Medicaid programs to increase options
in providing dialysis to populations not eligible for Medicaid, Medicare, or Medigap
programs. In twelve states and the District of Columbia, outpatient maintenance
dialysis is a covered benefit under the Medicaid program or under an emergency
program for defined populations not eligible for Medicaid. States where dialysis
services are covered via Medicaid programs and some modifications of an
emergency program are Arizona, California, Colorado, Illinois, Massachusetts,
Minnesota, New York, North Carolina, Pennsylvania, Virginia, Washington, and
Wisconsin.
Descriptions of the dialysis programs from the states with publicly available
information are detailed below. These states were profiled below because they have
taken a different approach to address coverage of routine dialysis services and had
information publicly available.
Arizona
Arizona provides dialysis services to Medicaid beneficiaries and non-citizens who
otherwise meet the requirement for Title XIX eligibility. The program reimburses
providers for emergency outpatient dialysis services provided to Federal Emergency
Services Program (FESP) members with ESRD “when the member’s physician,
nurse practitioner, or physician assistant signs a monthly certification stating that
the member requires dialysis services at least three times a week.” Free-standing
dialysis facilities providing services to this population are reimbursed under an all-
inclusive composite rate, which covers non-physician services, supplies, diagnostic
testing, and drugs. Details of dialysis services provided under Medicaid, the
certification form, and the federal emergency services program can be found at the
links in Appendix A.
Colorado
Colorado provides dialysis services via their state Emergency Medicaid (EM)
program. Applicants for EM must meet the same eligibility requirements as all other
Health First Colorado applicants, except for immigration or citizenship
requirements. The EM program covers medical emergencies only so all applicants
must be seeking treatment for a qualifying life- or limb-threatening medical
emergency. Dialysis for ESRD at an inpatient or freestanding dialysis center is
covered as an emergency medical condition. The dialysis services, or any
29
Revised: 12/2022
emergency medical condition, are covered by this program for the duration of the
emergency condition.
Illinois
Illinois modified their definition of emergency medical condition in 2018 to include
end stage renal disease (ESRD). Noncitizens who do not meet immigration
requirements and have ESRD can receive dialysis services. A physician’s note that
the noncitizen is receiving ESRD services is sufficient, which allows these patients
to bypass the medial determination process. Coverage is for dialysis services only
and each case is approved on an ongoing basis.
Minnesota
Minnesota covers a variety of services for noncitizens, regardless of immigration
status. Providers receive payment for services furnished to treat emergency
medical conditions. Dialysis services provided in a hospital or freestanding dialysis
facility are included in the state’s definition off emergency medical conditions.
Minnesota also includes kidney transplant in its definition of an emergency medical
condition if the noncitizen has been diagnosed with ESRD, is currently receiving
dialysis, and is a potential candidate for a kidney transplant.
North Carolina
North Carolina covers dialysis services for undocumented immigrants as an
emergency service. Under the state’s emergency Medicaid program, medical
emergencies are covered for the duration of the emergency. Each medical
emergency is required to be reviewed daily to determine if the undocumented
immigrant continues to have a qualifying emergency condition. “Once the condition
is stable enough to receive in-home hemodialysis without benefit of immediate
attention of the medical provider, the treatment is no longer an emergency
service.”
Washington
The state of Washington has an Alien Emergency Medical program. This program
provides coverage for individuals who do not meet citizenship or immigration status
requirements, including having not met the five-year immigration bar, and who
have a qualifying medical condition. Dialysis treatment is listed as a qualifying
emergency medical condition. Dialysis treatments, along with a few other
30
Revised: 12/2022
treatments, that do not require an inpatient hospital stay are covered for the
treatment of acute renal failure or ESRD.
Wisconsin
Wisconsin covers services for acute emergency medical conditions for certain non-
U.S. citizens who are not qualified immigrants. The state’s definition of an
emergency medical condition mirrors the federal definition but there is an added
comment that for the purposes of the policy, services for ESRD as well as all labor
and delivery services are considered emergency services.
31
Revised: 12/2022
Conclusion
Patients living with kidneys that do not function sufficiently may be diagnosed with
chronic kidney disease (CKD) which can progress to end-stage renal disease
(ESRD). The most effective way to improve the quality of care and reduce costs
related to CKD and ESRD is by slowing disease progression, reducing the amount of
people with diabetes and high blood pressure, and effective management of
patients who require routine dialysis. Additionally, preventing delays in treatment
can reduce or eliminate the need for costly emergency dialysis sessions and
inpatient hospital admissions.
A cost savings to the Medicaid program could be achieved by additional models

such as the research and programs summarized in this report which demonstrate
how delivering dialysis to patients in their home setting as compared to in a dialysis
center resulted in a cost savings. Value-based purchasing programs that monitor
kidney- and dialysis-related outcomes could improve quality and effectiveness of
care. Small pilot programs, such as the program from Parkland Hospital, can
improve care at the local level and result in cost savings due to increased efficiency
in patient care. Lastly, some states have redefined an emergency medical condition
to include the condition of ESRD to improve access to routine dialysis and prevent
crisis episodes necessitating emergency dialysis and possible inpatient admissions.
32
Revised: 12/2022
List of Acronyms
Acronym Full Name
ADU Acute Dialysis Unit
AEM Alien Emergency Medical
APM Alternative Payment Model
CAPD Continuous Ambulatory Peritoneal Dialysis
CCPD Continuous Cycle Peritoneal Dialysis
CHIRP Comprehensive Hospital Increase Reimbursement Program
CKD Chronic Kidney Disease
CMS Centers for Medicare and Medicaid Services
CRD Chronic Renal Disease
DPP Directed Payment Program
DSRIP Delivery System Reform Incentive Payment
ED Emergency Department
EM Emergency Medicaid
ESRD End Stage Renal Disease
ETC End-Stage Renal Disease (ESRD) Treatment Choices
FESP Federal Emergency Services Program
FPL Federal Poverty Level
HD Hemodialysis
HHSC Health and Human Services Commission
KHC Kidney Health Care
LIS Low Income Subside
MAGI Modified Adjusted Gross Income
MCO Managed Care Organization
P4Q Pay-for-Quality
PD Peritoneal Dialysis
PDP Prescription Drug Plans
PEMS Provider Enrollment and Management System
PPC Potentially Preventable Complications
QIPP Quality Incentive Payment Program
RRB Railroad Retirement Board
S.B. Senate Bill
SPAP State Pharmaceutical Assistance Program
SSN Social Security Number
TrOOP True Out-of-Pocket
UHRIP Uniform Hospital Rate Increase Program
VBP Value-Based Payment
33
Revised: 12/2022
References
American Kidney Fund. (n.d.) Stages of kidney disease. Retrieved from

https://www.kidneyfund.org/all-about-kidneys/stages-kidney-disease
Komenda, P. (2021). Costs of assisted home dialysis: A single-payer Canadian
model from Manitoba. Kidney Medicine, 3(6), 942-950. doi:
10.1016/j.xkme.2021.04.019
Berger, J.R., Quinones, H., & Vazquez, M.A. (2020). Dialysis for undocumented
immigrants: Challenges and solutions. Kidney 360, 1(6), 549-552. doi:
10.34067/KID.0000682020
Bryant, N. (2022). Riverside dialysis clinic: Dialysis in Houston for the uninsured.
Retrieved from https://houstoncasemanagers.com/riverside-clinic/
“CareLink Frequently Asked Questions.” (2022). Retrieved from

https://www.universityhealthsystem.com/patient-visitor-
resources/support/carelink/faqs
Cervantes, L., Johnson, T., Hill, A., & Ernest, M. (2020). Offering better standards
of dialysis care for immigrants. Clinical Journal of the American Society of
Nephrology, 15(10), 1516-1518. doi: 10.2215/CJN.01190120

https://acpinternist.org/archives/2021/02/getting-dialysis-for-undocumented-
patients.htm
End Stage Renal Disease (ESRD) Prospective Payment System (PPS). (2021,
December 22). Centers for Medicare and Medicaid Services. Retrieved May 10,
2022, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ESRDpayment?msclkid=b3b4c57dcfce11eca389aa42fd77d837
ESRD Treatment Choices (ETC) Model. (2022, May 9). Centers for Medicare and
Medicaid Services. Retrieved May 9, 2022, from
https://innovation.cms.gov/innovation-models/esrd-treatment-choices-model
34
Revised: 12/2022
Krahn, M.D., Bremner, K.E., de Oliveira, D., Dixon, S.N., McFarlane, P., Garg, A.X.,
Mitsakakis, N., Blake, P.G., Harvey, R., & Pechlivanoglou, P. (2019). Home dialysis
is associated with lower costs and better survival than other modalities: A
population-based study in Ontario, Canada. Peritoneal Dialysis International, 39(6),
553–561. doi:10.3747/pdi.2018.00268
Khullar, D. & Chokshi, D.A. (2019). Immigrant health, value-based care, and
emergency Medicaid reform. Journal of the American Medical Association (JAMA),
321(10), 928-929. doi: 10.1001/jama.2019.0839
Medicare.gov (2022). Parts of Medicare. Retrieved from

https://www.medicare.gov/basics/get-started-with-medicare/medicare-
basics/parts-of-medicare
Mody, S.H. (2004). Reducing the economic and clinical burden of CKD in the
managed care setting. Biotechnology Healthcare, 1(5), 56-61.
National Center for Chronic Disease Prevention and Health Promotion. (2022, May
6). Chronic diseases in America. Retrieved from
https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
National Center for Chronic Disease Prevention and Health Promotion. (2022).
Health and economic costs of chronic diseases. Retrieved from
https://www.cdc.gov/chronicdisease/about/costs/index.htm
National Kidney Foundation Inc. (2022). Kidney Disease: The Basics. Retrieved
from https://www.kidney.org/news/newsroom/fsindex
National Kidney Foundation. (n.d.). What is kidney failure?

https://www.kidney.org/atoz/content/KidneyFailure?msclkid=f66873b4d16511ec8c
580bbf01542447

emergency-only dialysis with health outcomes and costs in undocumented
immigrants with end-stage renal disease. Journal of the American Medical
Association Internal Medicine, 179(2), 175-183. doi:
10.1001/jamainternmed.2018.5866
“Patient Eligibility”. (n.d.) Retrieved from https://www.harrishealth.org/access-

care/patient-eligibility
“Riverside Dialysis Center. (n.d.). Retrieved from

https://www.harrishealth.org/locations-hh/Pages/riverside-dialysis-center.aspx
35
Revised: 12/2022
Rizzolo, K., Novick, T.K., & Cervantes, L. (2020). Dialysis care for undocumented
immigrants with kidney failure in the COVID-19 era: Public health implications and
policy recommendations. American Journal of Kidney Disease, 76(2), 255-257. doi:
10.1053/j.ajkd.2020.05.001
Texas Health and Safety Code. Title 4. Health Facilities, Subtitle D. Hospital
Districts, Chapter 286. Hospital Districts Created by Voter Approval, Subchapter A.,
General Provisions. Available at
https://statutes.capitol.texas.gov/Docs/HS/htm/HS.286.htm
United States Renal Data System. (2020). USRDS Annual Data Report:
Epidemiology of kidney disease in the United States. National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD,
2020.
United States Renal Data System. (2020). USRDS Annual Data Report:
Epidemiology of kidney disease in the United States. National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD,
2021

“What is MAP and MAP Basic?” (2022). Retrieved from

https://www.centralhealth.net/map/
36
Revised: 12/2022
Appendix A. Referenced Resources
13th Edition Texas Medicaid and CHIP Reference Guide
42 CFR § 440.255
2021 Minnesota Statutes 256B.06 Eligibility Migrant Workers Citizenship
Advancing American Kidney Health
Arizona’s Coverage of Dialysis Services
Arizona’s Initial Case Creation Form for Dialysis Services
Arizona’s Dialysis Certification Form
Arizona’s Federal Emergency Services Program
Colorado’s Emergency Medicaid Program
ESRD Billing Requirements (novitas-solutions.com)
ESRD General Information | CMS
ESRD Prospective Payment System (PPS) | CMS
ESRD Treatment Choices (ETC) Model
Illinois Department of Human Services Emergency Medical Coverage for Noncitizens

Not Meeting Immigration Status
KHC Program Report FY 2019
Medicare Claims Processing Manual (cms.gov)
Medicare Coverage of Kidney Dialysis & Kidney Transplant Services booklet
NC Division of Medical Assistance End-Stage Renal Disease
Washington State Health Care Authority Health Care Services and Supports
Noncitizens
Wisconsin Forward Health Non-U.S. Citizens Emergency Services
A-1
Revised: 12/2022
Appendix B. Types of Dialysis
Frequently
Asked
Questions Hemodialysis Peritoneal Dialysis
What is it? Blood flows through tubes, called A fluid, called dialysate, is put into the
catheters, to a machine that cleans it abdominal cavity via a catheter. The
by removing wastes and toxins. Blood dialysate stays in for a few hours while
is then returned to your body through it cleans the blood then is removed
the catheter. through the same catheter.
Where is it Can be done in the hospital, a dialysis Can be done in the hospital, a dialysis
done? center, or at home center, or at home
Who will A nurse or dialysis technician. Patients Patients can be trained to do their own
perform the can be trained to do their own dialysis dialysis at home. Help may or may not
treatment? at home with help from a nurse, tech, be needed from a nurse, tech, or
or family member. family member.
How long 2-4 hours, 3 times per week Typically done overnight while the
does it patient sleeps or several times
take? throughout the day.
Source:
https://www.kidneyfund.org/treatments/dialysis?gclid=EAIaIQobChMI5PHKwIHJ9wI
VbxXUAR2-PAhHEAAYBCAAEgIqm_D_BwE
B-1
Revised: 12/2022
Appendix C. Texas Medicaid Inpatient
and Outpatient – Professional
Utilization of Renal Dialysis Services,
State Fiscal Year 2018-2021, Medicaid
Total
Table C1. Texas Medicaid Inpatient and Outpatient – Professional Utilization of
Renal Dialysis Services for Medicaid Total, State Fiscal Year 2018
Average Amount
Modality Clients Amount Paid Paid per Client
Continuous Ambulatory Peritoneal 60 $376,342.57 $6,272.38
Dialysis (CAPD), In Center
Continuous Cycling Peritoneal Dialysis 179 $921,407.13 $5,147.53
(CCPD), In Center
Hemodialysis, In Center 4,695 $60,801,250.22 $12,950.21
Intermittent Peritoneal Dialysis (IPD), 6 $9,232.49 $1,538.75

In Center
Other/General Dialysis, In Center 399 $467,151.95 $1,170.81
Physician Services - ESRD, In Center 15,883 $4,370,914.09 $275.19
Physician Services - Hemodialysis, In 8,609 $8,025,990.49 $932.28

Center
Unscheduled/Emergency dialysis, In 119 $26,005.45 $218.53
Center
Physician Services - ESRD, Home 43 46,707.39 $155.99
Physician Services - Hemodialysis, 9 $191,490.00 $21,276.67

Home
Total 19,191 $75,196,491.78 $3,918.32

Average Amount
C-1
Revised: 12/2022
Average Amount
Continuous Cycling Peritoneal Dialysis 197 $1,287,865.45 $6,537.39
(CCPD), In Center

In Center
Physician Services - Hemodialysis, In 8,441 $8,868,476.03 $1,050.64

Center
Center
Physician Services - ESRD, Home 86 $15,881.71 $184.67

Home
Total 19,686 $81,293,067.11 $4,129.49

Average Amount
(CCPD), In Center

In Center

Center
Center
C-2
Revised: 12/2022
Average Amount

Home
Total 18,532 $84,642,392.76 $4,567.36

Average Amount
(CCPD), In Center
Intermittent Peritoneal Dialysis (IPD), 11 $4,967.24 $451.57

In Center

Center
Center
Physician Services - Hemodialysis, 2 $655.33 $327.67

Home
Total 17,271 $83,96,354.61 $4,828.69
Note: Client counts are unduplicated based on the Medicaid patient control number
(PCN). Subtotals may sum to more than the unduplicated total because some
clients were in more than one of the subtotal groups. The fee-for-service paid
amount represents the cost of services paid by Medicaid. Expenditures reflect client
services only and do not include administrative, capitation, and supplemental
payments. Medicaid managed care is paid on a capitation basis. The managed care
paid amount represents the cost of services as reported by the managed care
health plans.
C-3
Revised: 12/2022
Appendix D. Texas Medicaid Inpatient
and Outpatient – Professional
Utilization of Renal Dialysis Services,
State Fiscal Year 2018-2021,
Emergency Medicaid (TP30)
Table D1. Texas Medicaid Inpatient and Outpatient – Professional Utilization of

Renal Dialysis Services for the Emergency Medicaid (TP30) Program, State Fiscal
Year 2018
Average Amount
Continuous Ambulatory Peritoneal 0 $0.00 $0.00
Continuous Cycling Peritoneal Dialysis 1 $124.15 $124.15
(CCPD), In Center
Hemodialysis, In Center 63 $145,775.70 $2,313.90
Intermittent Peritoneal Dialysis (IPD), 0 $0.00 $0.00

In Center
Physician Services - ESRD, In Center 132 $5,794.12 $43.89
Physician Services - Hemodialysis, In 342 $84,415.24 $246.86

Center
Unscheduled/Emergency Dialysis, In 58 $11,878.63 $204.80
Center
Physician Services - ESRD, Home 0 $0.00 $0.00

Home
Total 514 $351,903.86 $684.64

Year 2019
Average Amount
Continuous Ambulatory Peritoneal 0 0.00 0.00
Continuous Cycling Peritoneal Dialysis 0 0.00 0.00
(CCPD), In Center
D-1
Revised: 12/2022
Average Amount

In Center

Center
Center

Home
Total 553 $335,765.67 $607.17

Year 2020
Average Amount
Continuous Cycling Peritoneal Dialysis 0 $0.00 $0.00
(CCPD), In Center

In Center

Center
Center

Home
Total 508 $432,220.70 $850.83
D-2
Revised: 12/2022
Year 2021
Average Amount
Continuous Cycling Peritoneal Dialysis 1 $7,230.06 $7,230.06
(CCPD), In Center

In Center
Physician Services - ESRD, In Center 28 $856.94 $30.61

Center
Center

Home
Total 377 $358,548.53 $951.06
D-3
Revised: 12/2022

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Cost Effective and

Texas Health and Human Services

Cost Effective Dialysis in Texas Medicaid .................................................. 20

List of Acronyms ....................................................................................... 33

Appendix A. Referenced Resources ............................................................. 1

Appendix B. Types of Dialysis ..................................................................... 1

Appendix C. Texas Medicaid Inpatient and Outpatient – Professional

Appendix D. Texas Medicaid Inpatient and Outpatient – Professional

● The Medicare End-Stage Renal Disease Treatment Choices model and

● Alternatives to providing dialysis to persons under emergency Medicaid to

Recent treatment models encourage dialysis treatment in the home setting to

Connecting people with preventive services to manage precursor conditions can

The severity of disease progression and illness is categorized by staging

Table 2. Prevalence of CKD by stage, 2015-2018

Table 3a. Prevalence of CKD (%) by health insurance coverage, 2003-2018

Table 3b. Prevalence of CKD (%) by health insurance type, 2003-2018

Table 5a. Prevalence of CKD (%), by presence of diabetes mellitus and

Table 5b. Prevalence of CKD (%), by presence of diabetes mellitus and

Table 5c. Prevalence of CKD (%), by presence of diabetes mellitus and

Table 5d. Prevalence of CKD (%), by presence of diabetes mellitus and

Overview of End-Stage Renal Disease in

How Dialysis Services are Covered in Texas

● Live in and intend to remain in Texas

● All items and services included under the composite rate

● Home and self-dialysis training, and

● Removed Method II composite rate

Appendix A of this report includes claims processing details, the prospective

Table 6a. Texas Medicaid Inpatient and Outpatient – Professional Utilization of

Table 7. Texas Medicaid Inpatient and Outpatient – Professional Utilization of

2019 553 $335,765.67 $607.17

2020 508 $432,220.70 $850.83

2021 377 $358,548.53 $951.06

Table 8. Parts of Medicare

Medicare Partn Description

Part C (Medicare Advantage) A Medicare-approved plan from a private company that

Kidney Health Care Program

● Have a diagnosis of ESRD certified by physician;

● Receive regular dialysis treatments or have received a kidney transplant;

1,894 Home Dialysis 14% 9%

7,826 Transplant N/A 37%

Medicare End-Stage Renal Disease Treatment

● A uniformly positive adjustment on Medicare claims for home dialysis during

● A per treatment payment adjustment, either upward or downward, for

Home Dialysis Cost Effectiveness

A single-center study from Manitoba, Canada implemented a cost minimization

1-Year $50,502.51 $31,111.64 $40,001.28 $51,397.52 $56,662.95 $45,580.75 $48,265.50

Savings N/A $19,390.87 $10,501.23 ($895.01) ($6,160.44) $4,921.77 $2,237.01

Value-Based Purchasing Models for Dialysis

● Managed Care Value-Based Payment Programs,

Figure 3. Changes in hospital PPC performance for 2014–2016

These trends indicate the need to adopt interventions to reduce complications,

Innovative Delivery Models

Delivery System Reform Incentive Payment

Starting in Demonstration year (DY4) (October 1, 2014), patients were selected to

Parkland Hospital submitted data throughout the project for evaluation of

Alternative Models of Care in Texas

Specifically for Harris Health Financial Assistance Program members, dialysis

Alternatives to Providing Dialysis via

In multiple studies analyzing the effects of scheduled dialysis programs, actual