CMS Pub. 100-16, ch. mc86c17b, § 240

Individuals who have been medically determined to have ESRD are not eligible to elect

to enroll in a cost-based HMO/CMP. However, individuals already enrolled in the

organization who subsequently become eligible for Medicare because of ESRD, and aged

Medicare enrollees who subsequently develop ESRD, cannot be disenrolled from the

organization as a result of the development of ESRD. Special limitations apply to

Medicare program payment for ESRD services. For dialysis and related services, CMS

carriers process physician claims and CMS intermediaries process facility claims.

The amount CMS pays to a cost-based HMO/CMP for services rendered to individuals

with ESRD will be limited to the amount CMS would otherwise pay for services rendered

to these individuals if they were not enrollees of the organization. Generally, effective on

or after August 1, 1983, Medicare payment for ESRD services is made to the dialysis

facility on the basis of one of two prospective composite rates: one rate for hospital-based

ESRD facilities and one rate for independent dialysis facilities. Patients dialyzing at

home have the option of having these services paid for under the composite rate system

or dealing directly with the Medicare program to receive payment on a FFS basis for

items and services provided.

For a full discussion of ESRD reimbursement under Medicare, see Chapter 27 of the

“Provider Reimbursement Manual” (Pub. 15), Part I. In addition, general information on

coverage, entitlement, and billing for ESRD services under Medicare can be obtained

from either the Renal Dialysis Facility Manual or the Hospital Manual.