30 Mar 0
PACE programs don’t often face the possibility of a participant receiving a renal transplant. However, most Executive Directors and Medical Directors worry that, should that situation arise, that the cost would be prohibitive and that their program could never absorb the financial burden. Fortunately, that is not the case.
Your dialysis participants don’t use the Version 21 HCC model that is used to calculate risk scores for your other participants. Instead they use CMS HCC – ESRD model. Imbedded into that model is funding for a renal transplantation. The model looks at the cost of renal transplantation incurred over three months. Through the development of new risk scores (which won’t be dealt with here), CMS pays over 50% of the cost for the transplantation in the first month and the remainder divided equally over the next two months.
After the third month, the transplant participant uses a different subset of the CMS HCC-ESRD model for payment which is called the “functioning graft” model. Here a risk score is generated for months 4 through 9, and a separate risk score for months 10 and greater.
The take home point is this: Relax. If your participant is in need of a renal transplant, CMS will provide additional funding so that this will not be a financial burden to your program.