Abstract: SA-PO0929
Mapping Medigap Access and Affordability Protections for Patients with ESRD: A Legal Epidemiology Analysis
Session Information
- Top Trainee Posters - 3
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 01:30 PM - 01:36 PM
Category: Diversity and Equity in Kidney Health
- 900 Diversity and Equity in Kidney Health
Authors
- Ahmed, Umayr, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
- Hawa, Mikhail Ismail, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
- Zhao, Yueming, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
- Yearby, Ruqaiijah, Temple University, Philadelphia, Pennsylvania, United States
- Tummalapalli, Sri Lekha, Weill Cornell Medicine, New York, New York, United States
- Reddy, Yuvaram N.V., University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
Background
Patients with end-stage renal disease (ESRD) enrolled in Medicare Fee-For-Service are faced with significant out-of-pocket costs. These include 20% co-insurance for outpatient dialysis treatments within Medicare Part B, which exceed $5,000 per year. Patients often rely on private Medigap supplemental plans to cover these out-of-pocket costs. However, Medigap availability for patients with ESRD varies by state because federal law does not require insurers to offer Medigap to individuals under age 65. Some states have laws that require plans to be offered (access protections), others require fair premiums (affordability protections), and some have no protections. As a first step toward understanding how access to Medigap affects ESRD outcomes, we used legal epidemiology to map state-level protections.
Methods
Using the Nexis Uni database, we reviewed statutes and administrative codes in all 50 states to identify two types of protections: access (whether insurers must offer Medigap to patients with ESRD under 65, known as "guaranteed issue") and affordability (whether states cap premiums or require community rating). We conducted background internet research to develop search strings for identifying relevant statutes and regulations in Nexis Uni. Two researchers independently reviewed and coded each state; disagreements were resolved with the broader team, including a legal expert.
Results
We identified 21 states with Medigap access protections for patients with ESRD under 65, and 8 were enacted in the last ten years. Florida, for example, requires Medigap insurers to offer policies to persons eligible "by reason of disability or end-stage renal disease." Additionally, 14 states had affordability protections. Idaho, for instance, caps under-65 premiums at "one hundred fifty percent (150%) of the premium" of a similarly rated 65-year-old, while New Hampshire prohibits rates that exceed "the highest rate proposed for a policyholder greater than age 65."
Conclusion
We found that the majority of states (29 in total) lack legislation or regulation guaranteeing Medigap access for patients with ESRD under 65, while 36 states lack affordability protections. To inform future policy reform at the state and federal level, more research is needed to understand how access to Medigap may affect clinical outcomes for patients with ESRD.