Expanded Medicare Coverage of Immunosuppressive Drugs for Kidney Transplant Recipients
Frequently Asked Questions:
As of January 1, 2023, kidney transplant recipients will qualify for lifetime Medicare coverage of their immunosuppressive drugs, regardless of age, if they do not have other insurance coverage as described below. Before this, people who were eligible for Medicare because of end-stage kidney failure (rather than age or disability), lost coverage for their immunosuppressive medications 36 months post-transplant. Many patients struggle to pay for these drugs, leading to rationing or stopping taking the medications entirely, either of which greatly increases the risk of the transplant failing and the patient returning to dialysis. Many others did not even try to get a transplant for fear of not being able to afford their immunosuppressive drugs 36 months after their transplant.
Who is eligible for the indefinite coverage?
Anyone who meets the following criteria are eligible for indefinite coverage of their transplant immunosuppressive medications under Medicare Part B (referred to as Medicare Part B-ID):
- Received a kidney transplant from a Medicare-approved facility.
- Does not have Medicaid.
- Medicare coverage under Part A has ended.
- Does not have other public or private health insurance with an immunosuppressive benefit.
Public insurance includes Medicaid, Department of Veterans Affairs coverage, or TRICARE (for civilian Armed Forces personnel and retirees). Private insurance examples include a group health plan (HMO, PPO), employer-based plan, coverage under the Affordable Care Act, or individual health insurance plan. It is important to note that the Part B-ID benefit extends Medicare only for immunosuppressive drug coverage. The forms of health insurance described here provide more extensive, comprehensive coverage. If you qualify for these or any other health insurance, you should explore those options to obtain broader health benefits and coverage.
When will I be able to get the extended immunosuppressive coverage?
The extended eligibility becomes effective on January 1, 2023 and enrollment began on October 1, 2022 for kidney transplant recipients whose Medicare has ended. Kidney transplant recipients whose Medicare entitlement ends on or after January 1, 2023 can enroll for the immunosuppressive coverage at any time. Contact the Social Security Administration at 1-877-465-0355 to enroll (TTY use 1-800-325-0778).
If my Medicare coverage expires prior to the January 1, 2023 effective date, will I be eligible?
Yes. Anyone who had a transplant and whose Medicare eligibility expires before, on, or after January 1, 2023 can enroll in Medicare Part B solely for immunosuppressive coverage if they do not have other insurance for their immunosuppressive drugs. The enrollment period for anyone whose Medicare coverage ends prior to January 1, 2023 began on October 1, 2022.
What actions will I be required to take to enroll?
You will have to apply to determine if you meet the necessary requirements (see above). Kidney recipients who are non-aged or non-disabled receive a letter from Social Security as their 36-month post-transplant date draws near. Going forward, the written notification will include information on the extended immunosuppressive benefit and eligibility.
I have Medicare and Medicaid. Do I qualify for the indefinite Medicare immunosuppressive coverage?
No. Your immunosuppressive medications will be covered by your state’s Medicaid plan, if you maintain that insurance coverage. If you lose both traditional Medicare and Medicaid coverage, you can apply for the Medicare immunosuppressive coverage.
What if I am eligible for the new benefit but I later obtain coverage that includes immunosuppressive coverage?
You will be required to notify the Social Security Administration (SSA) within 60 days of enrollment in your new insurance coverage.
What if I have other coverage for my immunosuppressives, but lose that coverage at a future date?
If you have separate coverage but lose it in the future (for example, you have employer-based coverage but leave your employer at some point), you can enroll in the Medicare immunosuppressive program at that time as long as you meet the qualifications in the Who is Eligible for the Indefinite Coverage? section above.
Will I continue to have other Medicare covered benefits 36 months after transplant?
No. All other Medicare benefits for kidney recipients who are under 65 and not eligible for Medicare based on a disability other than kidney failure would still end three years (36 months) after the transplant. Once you reach age 65 (or qualify for Medicare based on disability other than kidney failure), you will be eligible for full Medicare Part A and Part B coverage.
Are other transplant related medications covered under the extension?
No, only immunosuppressive drugs are covered indefinitely. Nor are any other medical services related to your transplant, such as annual lab tests, covered 36 months after the transplant.
Will I be charged the full Part B monthly premium that I currently pay or previously paid before my Medicare eligibility ended?
No. Since your Medicare coverage after 36 months is limited to immunosuppressive drugs, the monthly premium will be equal to 15 percent of the monthly rate for Medicare beneficiaries age 65 and over. The amount will be determined by the U.S. Department of Health and Human Services (HHS) in September of each year. For 2023, the monthly premium for the limited immunosuppressive benefit will be $97.10. This is equivalent to 15% of the combined individual and HHS portion of the full Part B benefit ($659.60 in 2023).
You might qualify for assistance to help pay the monthly premiums and cost-sharing. Individuals who enroll Part B-ID should contact their state Medicaid agencies to find out if they are eligible for Medicare Savings Programs (MSPs). Eligibility for MSPs for Part B-ID is subject to income limits and asset limits. These limits can vary depending on the particular state.
Will I be required to pay the standard 20% copay under Medicare Part B?
Yes, the new benefit will require a 20% copay for the prescribed immunosuppressive drugs, similar to other services under Part B for full Medicare beneficiaries.
Will the extension be limited to specific immunosuppressive drugs, or to generics?
No. Since effectiveness of immunosuppressive drugs for kidney recipients can differ among patients, your transplant physician will continue to prescribe the medications most beneficial for you. The National Kidney Foundation expressed the importance of making all FDA-approved transplant immunosuppressive drugs available to a transplant patient’s care team in our discussions with Congress and Federal agencies.
Additional questions or concerns?
Visit Medicare website to learn more. NKF continues to work with pharmaceutical companies, state assistance programs and others to prevent gaps in coverage. If you are having trouble affording your medications, contact our NKF Cares Helpline for assistance: 1-855-653-2273 or email@example.com.