The Medicare Advantage standard, ER16, provides:

The MAO does not deny or discourage enrollment on the basis of health status except for ESRD. In certain exceptional cases, even beneficiaries with ESRD may not be denied enrollment or discouraged from enrolling.

The Basics

The URAC standard that supports this is MAP-AD 2.  That standard prohibits your organization from enrolling a person with the end-stage renal disease.  However, once a person is enrolled in your plan, your organization may not disenroll that person if he/she develops end-stage renal disease after enrollment.  What is important to notice is that, for the limited purposes of this standard, a person is considered "enrolled" in the organization if he/she lives in your organization's service area at the time he/she first becomes eligible for the plan.

Management Tips

Be sure to have clear policies and procedures outlining this specific situation.  In addition, make sure that your staff is well-trained to handle ESRD enrollment issues, particularly because enrollment in this context is different than enrollment in most contexts that members of your staff will face.

URAC Accreditation Tips

The desktop review will involve an examination of your policies and procedures, complaint and grievance logs, and correspondence regarding enrollment or denial of enrollment.  In addition, you should submit documentation demonstrating staff training around your policies and procedures dealing with this standard.

During the onsite review, the reviewer will talk to your enrollment staff and compliance officer.  Some of the questions that are likely to come up will include an inquiry as to which Medicare enrollees are not eligible to participate in the plan, or a more direct question, such as whether somebody with end-stage renal disease enroll in your plan.  The reviewer is also likely to ask about how you'd disenroll your members, and where members would find out more information about disenrollment.  The reviewer also is likely to review your complaint log in search of complaints about improper disenrollment.

The standard is also supported by the Core standard dealing with regulatory compliance (Core 4 in v. 3.0), which you have already reviewed.

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