Kidney Care Demonstration Program

Summary#

This bill creates a 10-year federal demonstration to pay health plans for taking steps that prevent or delay progression of kidney disease to end-stage renal disease (ESRD). Participating plans must cover and promote defined kidney care services, screen enrollees at no cost, report data to the government, and may receive a share of estimated Medicare savings if their patients progress to ESRD less often than expected. The goal is to increase early detection and treatment of kidney disease and to reduce Medicare spending tied to ESRD.

Key changes:

• New demonstration program: A multipayer program starts by January 1, 2027 and runs 10 years to test shared-savings payments tied to prevention of ESRD.
• Required plan actions: Participating plans must provide specified kidney care services, apply the lowest cost sharing for those services, and provide free kidney-disease screening for all enrollees.
• Data and evaluation: Plans must submit historical and ongoing data (including protected health information) so the Secretary can set benchmarks, verify results, and evaluate effects.
• Shared savings: If a plan’s adjusted progression rates fall below a benchmark, the plan can receive 25% of estimated Medicare savings certified by the Medicare actuary.
• Funding and administration: $5 million per year (fiscal 2026–2038) is transferred for program administration; shared-savings and advance payments for program years 2027–2037 come from Medicare trust funds.
• Flexibility and waivers: The Secretary may waive certain statutory requirements and exempt the program from the Paperwork Reduction Act for implementation.

What it means for you#

• Patients with kidney disease

  • You could get more screening, education, nutrition support, and disease management services covered by your plan.
  • Screening for kidney disease must be covered without cost-sharing.
  • Telehealth may be used for kidney services if appropriate.

• People at risk of kidney disease (diabetes, hypertension, family history)

  • Plans participating in the program must develop screening plans and may increase outreach to find and treat early-stage disease.

• People with private insurance, Medicaid, or Medicare Advantage

  • Group health plans, commercial insurers, Medicaid programs, Medicaid managed care plans, and Medicare Advantage plans can apply to join the program.
  • Participating plans must apply the plan’s lowest cost-sharing level to the specified kidney services.

• Health plans and insurers

  • Must submit detailed data about members’ kidney disease prevalence, progression, service use, and outcomes.
  • Must cover specified kidney services and screening, limit restrictive management of kidney drugs beyond FDA labeling, and may receive advance investment payments or shared-savings payments.
  • Face potential termination, payment recoupment, or denial of shared savings if they game enrollment or fail to follow program rules.

• Clinicians and providers

  • Could see more referrals for screening and early-stage kidney care.
  • Telehealth and certain drugs for slowing kidney decline are explicitly included as covered services.

• Medicare program / taxpayers

  • The program aims to reduce Medicare spending on ESRD by paying plans that demonstrably lower progression to ESRD; actual savings and net effects are to be measured and reported.

• Privacy

  • Plans will share protected health information with the federal government for verification and evaluation.

Expenses#

Estimated public cost: The bill sets aside $5,000,000 per fiscal year for administration (fiscal years 2026–2038). The total cost for shared-savings payments and advance investment payments is not estimated in the bill.

• Administrative funding: $5 million per year transferred from Medicare trust funds for CMS program management, available until spent.
• Shared savings and advance payments: Payments for program years 2027–2037 will come from Medicare trust funds; the bill does not state a dollar estimate or cap.
• Plan costs: Participating plans will likely have costs to expand screening, cover additional services at lower cost-sharing, collect and submit data, and possibly repay advance payments if shared savings are smaller than advances.
• Potential recoupment: The Secretary may recoup shared savings already paid if a plan is terminated for noncompliance.
• No full fiscal note provided in the bill text: No overall estimate of net Medicare savings or program costs is given in the available material.

Proponents' View#

• The bill appears intended to shift payment incentives so plans invest in early detection and treatment that slow progression to ESRD.
• Supporters may argue that linking a portion of Medicare savings to plan actions could encourage broader, earlier screening and care across private, Medicaid, and Medicare Advantage plans.
• The program could increase access to kidney-specific drugs, nutrition, counseling, and community-based supports that help preserve kidney function.
• The independent evaluations required by the bill could show whether multipayer shared-savings models reduce ESRD rates and lower Medicare spending.

Opponents' View#

• One concern is that the bill leaves key details to the Secretary, so the exact scope of covered services, selection of participating plans, and benchmark methods are unclear.
• The amount of shared savings to be paid is unspecified beyond the 25% share; it is unclear whether payments or savings will be large enough to change plan behavior.
• Requiring plans to submit protected health information raises privacy and data-security questions.
• The program draws payments from Medicare trust funds to pay plans and for advances; opponents may point out risk to trust fund balances if projected savings do not materialize.
• Administrative and reporting burdens on plans and on CMS could be sizable; the bill exempts the program from the Paperwork Reduction Act, which may raise oversight concerns.
• There is a risk plans might try to avoid enrolling higher-risk patients to improve measured performance; the bill authorizes penalties but the effectiveness of safeguards depends on implementation.