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Federal Register / Vol. 86, No. 129 / Friday, July 9, 2021 / Proposed Rules
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Column A of the impact table indicates the number of ESRD facilities for each impact category and column B
indicates the number of dialysis treatments in millions. The overall effect of the proposed changes to the outlier payment policy described in section II.B.1.c of this proposed rule is shown in column C. For CY 2022, the impact on all ESRD facilities as a result of the proposed changes to the outlier payment policy would be a 0.2 percent increase in estimated payments. All ESRD facilities are anticipated to experience a positive effect in their estimated CY 2022 payments as a result of the proposed outlier policy changes.
Column D shows the effect of the annual update to the wage index, as described in section II.B.1.b of this proposed rule. That is, this column reflects the update from the CY 2021
ESRD PPS wage index using 2018 OMB
delineations as finalized in the CY 2021
ESRD PPS final rule, with a basis of the FY 2022 pre-floor, pre-reclassified IPPS
hospital wage index data in a budget neutral manner. The total impact of this change is 0.0 percent; however, there are distributional effects of the change among different categories of ESRD
facilities. The categories of types of facilities in the impact table show changes in estimated payments ranging from a 0.7 percent decrease to a 0.5
percent increase due to the annual update to the ESRD PPS wage index.
Column E shows the effect of the proposed CY 2022 ESRD PPS payment rate update as described in section II.B.1.a of this proposed rule. The proposed ESRD PPS payment rate update is 1.0 percent, which reflects the proposed ESRDB market basket percentage increase factor for CY 2022
of 1.6 percent and the proposed productivity adjustment of 0.6 percent.
Column F reflects the overall impact, that is, the effects of the proposed outlier policy changes, the proposed updated wage index, and the payment rate update. We expect that overall ESRD facilities would experience a 1.2

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percent increase in estimated payments in CY 2022. The categories of types of facilities in the impact table show impacts ranging from a 0.4 percent increase to a 1.6 percent increase in their CY 2022 estimated payments.
b. Effects on Other Providers Under the ESRD PPS, Medicare pays ESRD facilities a single bundled payment for renal dialysis services, which may have been separately paid to other providers for example, laboratories, durable medical equipment suppliers, and pharmacies by Medicare prior to the implementation of the ESRD
PPS. Therefore, in CY 2022, we estimate that the proposed ESRD PPS would have zero impact on these other providers.
c. Effects on the Medicare Program We estimate that Medicare spending total Medicare program payments for ESRD facilities in CY 2022 would be approximately $8.9 billion. This estimate takes into account a projected decrease in fee-for-service Medicare dialysis beneficiary enrollment of 5.9
percent in CY 2022.
d. Effects on Medicare Beneficiaries Under the ESRD PPS, beneficiaries are responsible for paying 20 percent of the ESRD PPS payment amount. As a result of the projected 1.2 percent overall increase in the proposed CY 2022 ESRD
PPS payment amounts, we estimate that there would be an increase in beneficiary co-insurance payments of 1.2 percent in CY 2022, which translates to approximately $30 million.
e. Alternatives Considered CY 2022 Impacts: 2019 Versus 2020
Claims Data Each year CMS uses the latest available ESRD claims to update the outlier threshold, budget neutrality factor, and payment rates. Due to the COVID19 PHE, we compared the impact of using CY 2019 claims against CY 2020 claims to determine if there was any substantial difference in the
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results that would justify potentially deviating from our longstanding policy to use the latest available data. Analysis suggested that ESRD utilization did not change substantially during the pandemic, likely due to the patients vulnerability and need for these services. Consequently, we proposed to use the CY 2020 data because it does not negatively impact ESRD facilities and keeps with our longstanding policy to make updates using the latest available ESRD claims data.
2. Proposed Payment for Renal Dialysis Services Furnished to Individuals With AKI
a. Effects on ESRD Facilities To understand the impact of the changes affecting payments to different categories of ESRD facilities for renal dialysis services furnished to individuals with AKI, it is necessary to compare estimated payments in CY
2021 to estimated payments in CY 2022.
To estimate the impact among various types of ESRD facilities for renal dialysis services furnished to individuals with AKI, it is imperative that the estimates of payments in CY
2021 and CY 2022 contain similar inputs. Therefore, we simulated payments only for those ESRD facilities for which we are able to calculate both current payments and new payments.
For this proposed rule, we used CY
2020 data from the Part A and Part B
Common Working Files as of February 12, 2021, as a basis for Medicare for renal dialysis services furnished to individuals with AKI. We updated the 2020 claims to 2021 and 2022 using various updates. The proposed updates to the AKI payment amount are described in section III.B of this proposed rule. Table 10 shows the impact of the estimated CY 2022
payments for renal dialysis services furnished to individuals with AKI
compared to estimated payments for renal dialysis services furnished to individuals with AKI in CY 2021.
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