Wins for the Profession in Released Medicare ESRD Final Rule

The CY 2027 Medicare ESRD Final Rule was released on October 30, 2026, which included five out of five provisions that the Academy and Renal DPG provided comment on:

CMS is permanently building the cost of phosphate binders into the base rate now that their two-year TDAPA period ends on December 31, 2026.

Low-volume adjustment expanded – As proposed, CMS doubles the threshold for the low-volume payment adjustment (LVPA) from 4,000 to 8,000 treatments a year and moves from two tiers to six.

Home and self-dialysis training – CMS increases the training add-on from $95.60 to $138.00 per session (vs. $138.22 proposed, reflecting updated wage data) and, as proposed, allows training payments during a patient's first 120 days on dialysis (the "onset period").

A new Hyperphosphatemia clinical measure replaces the Hypercalcemia reporting measure. CMS rejected requests to phase it in as reporting-only first and kept its 6.5 mg/dL threshold.

Bigger post-TDAPA payments – Updated data pushed the post-TDAPA add-on for DefenCath^® to $8.32 per treatment, up from about $5.60 proposed. CMS now estimates post-TDAPA payments of about $290 million in 2027, up from roughly $34 million in 2026.

In addition, CMS wrote that they will consider the Academy's recommendation on a staffing ratio for dialysis clinics "to potentially inform future rulemaking." The recommendation to include the Malnutrition Care Score (MCS) in the ESRD QIP was not included in the proposed rule or final rule.

However, provisions not included in the proposed rule could potentially be included the following year but it is but is very unlikely to be adopted in the final rule because other organizations were not given a chance to comment on the provision.

The Academy will continue to work with the Renal DPG and other allied groups on potential sub-regulatory policy that is needed following this regulation, as well as advocate for the inclusion of a staffing ratio for dialysis clinics in next year's proposed rule and the inclusion of the MCS in the ESRD QIP.