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See Comments and Responses in the section titled “Organ Acquisition Costs for Kidney Transplants.” Section H. MA ESRD Rates Comment: The majority of commenters on this topic expressed concerns that ESRD rates are not sufficient to cover the cost of care for beneficiaries with ESRD. The commenters requested that CMS continue regular evaluations of ESRD rates to improve the adequacy and accuracy of MA ESRD benchmarks and payment, particularly given the increasing number of beneficiaries with ESRD in MA plans. A commenter requested that CMS share more information about its analysis of ESRD payments and costs. Commenters highlighted the potential consequences of inadequate rates, including impacts to all MA beneficiaries through increased premiums and cost-sharing, reduced benefits, and fewer plan options. Response: CMS appreciates the comments regarding MA ESRD payment adequacy given the increased enrollment into MA plans by beneficiaries with ESRD. CMS continues to analyze these issues and consider whether, consistent with the statutory requirements for setting ESRD rates in section 1853(a)(1)(H) of the Act, any refinements to the methodology may be warranted in future years to ensure appropriate ESRD payment rates. Comment: A majority of commenters on this topic expressed concern that the state-based rate- setting methodology results in rates that are inadequate to cover costs in certain markets. Many commenters stated that state-based rate setting masks within-state variations in ESRD costs and noted that expenditures for ESRD care in metropolitan areas can deviate from the state average, indicating the need for a more localized approach in setting payment rates. Commenters suggested CMS should continue to consider the use of smaller geographic areas as the basis for calculating MA ESRD benchmarks, and a few commenters stated CMS should provide more underlying data associated with the analysis of core-based statistical areas as an alternative to state-based payments. Commenters acknowledged that certain areas, such as rural and medically underserved areas, could receive lower rates under a new methodology and suggested CMS consider adjustments to these areas to ensure continued access to services. Response: CMS appreciates the comments regarding ESRD rate setting and refers commenters to the analyses of sub-state ESRD rates provided in the CY 2023 and CY 2024 Advance Notices. In the CY 2024 Advance Notice, CMS provided details of our analysis of potential changes in ESRD rates by Core-Based Statistical Areas (CBSA), showing that CBSAs representing the 40 percent of enrollment with the 68 highest area deprivation index (ADI) measures were expected to receive CY 2022 ESRD rates that were an average of 2.13 percent lower under the CBSA- level approach. CMS believes our longstanding rate-setting approach is fair and reasonable, and CMS agrees with commenters that significant changes to the current methodology should be fully examined prior to implementation. CMS will continue taking into consideration commenters’ concerns and recommendations.