Nearly six years after Congress opened up Medicare Advantage (MA) more widely to people with end-stage renal disease (ESRD), enrollment among this population has grown faster than federal regulators anticipated. The rising demand means nephrologists, dialysis providers, and other clinicians serving this population are exploring strategies to build more sophisticated payer-contracting capabilities, and MA organizations need sufficient networks of providers and clinically appropriate approaches to care coordination and utilization management.
The Cures Act and the Path to MA Enrollment with ESRD
The 21st Century Cures Act (Cures Act), signed into law on December 13, 2016, changed the landscape of Medicare payment for beneficiaries with ESRD. Before the Cures Act, Medicare beneficiaries with ESRD were largely prohibited from enrolling in MA plans, though those already enrolled could remain after their diagnosis. A small number of beneficiaries could enroll in ESRD-specific chronic condition special needs plans (C-SNPs) where available.
The Cures Act removed the MA enrollment restriction for people with ESRD, allowing all individuals with the condition to enroll in any MA plan regardless of when they were diagnosed or their prior coverage. This change, effective for plan years beginning January 1, 2021, laid the groundwork for the rapid rise in MA enrollment among people with ESRD.
By the Numbers: MA Enrollment Among People with ESRD
At the time the Cures Act was passed, CMS estimated that MA plan enrollment would increase by 83,000 beneficiaries with ESRD over six years, of whom 41,500 would enroll in 2021. ATI Advisory analyzed the 2020–2026 Master Beneficiary Summary File (MBSF) data to understand the actual growth in MA enrollment among this population. ATI’s analysis found that enrollment exceeded CMS’s original projections for the first year and has been climbing ever since.
Between January 2020–January 2026, MA enrollment among beneficiaries with ESRD grew from approximately 125,000 to almost 280,000 beneficiaries.* This figure represents more than 50 percent of all Medicare beneficiaries with ESRD and nearly double original projections. MA enrollment has quickly redefined how care is delivered for this population, and this growth is expected to continue.
What Rising MA Enrollment Means for ESRD Providers and MA Organizations
This rapid growth in MA enrollment among beneficiaries with ESRD has significant implications for the providers and plans who serve them. Prior to the Cures Act, payment to nephrologists, dialysis providers, and others delivering healthcare to people with ESRD was determined primarily by Medicare fee-for-service payment policy, which is standardized across beneficiaries with predictable adjustments for geography, clinical complexity, and other factors.
Now that the majority of beneficiaries with ESRD are enrolled in MA, nephrologists, dialysis providers, and MA plans are balancing administrative demands, including:
- Negotiating payment rates and other contracting terms for ESRD-related services;
- Navigating prior authorization and other utilization management approaches; and
- Managing and participating in provider networks while monitoring how they affect patients’ access to dialysis facilities and specialists.
As the number of people with ESRD enrolling in MA continues to increase, operational demands are likely to intensify, requiring enhanced partnerships between nephrology practices, dialysis organizations, and MA organizations to provide accessible, high-quality care.
ATI’s analysis underscores that MA is now a central financing mechanism for ESRD care, and that payment, network design, and utilization management decisions in MA will shape outcomes for this high-need population. Understanding how MA plans structure care for this group will be essential to ensuring access, quality, and cost predictability keep pace with enrollment growth.
*Analysis based on Medicare enrollment data reflected in the 2020-2026 Master Beneficiary Summary File for beneficiaries with a Monthly Medicare Status Code indicating ESRD (‘Aged with ESRD (11),’ ‘Disabled with ESRD (21),’ and ‘ESRD only (31)’).