New Law to Help Vulnerable Transplant Recipients in 2023
An Upcoming Change in Payment for Transplant Drugs
Many people with kidney failure want a transplant, and a financial assessment is part of the evaluation. Transplant and dialysis staff have known patients who lost Medicare after 36 months, were unable to afford their drugs—and did not take them as ordered. They have known patients who lost the kidney and ended up back on dialysis or died. Multiple studies have reported a higher risk of transplant loss when Medicare no longer covers immunosuppressant drugs.1 Yet, Medicare’s Part A and B costs in 2018 for a transplant recipient after the transplant year was much less than dialysis: $28,106. And, the Medicare Part B cost per transplant recipient for immunosuppressants alone was just $2,453, vs. $91,860 for Medicare’s Part A and B costs for a dialysis patient.2
Medicare and Transplant: The Old Way
Original Medicare Part B covered and still covers transplant drugs at 80% after the annual deductible, IF:
The patient had Medicare Part A in effect the month of the transplant as a primary or secondary payer, whether Medicare paid for the transplant or not.
The patient had the transplant surgery at a Medicare approved transplant program.
The patient had Medicare Part B in effect when the drugs were ordered.
How long Medicare Part B covered these drugs would depend. People age 65 and older and those with Medicare due to another disability besides ESRD could keep Medicare for all Medicare-covered services, including transplant drugs, if they paid the Part B premium. But, when someone who had Medicare only because of ESRD got a transplant, Part A and B ended 36 months post-transplant—which ended Medicare’s coverage for immunosuppressants. Or, at least, that is how it was for decades.
Advocacy for Lifetime Coverage
The renal community has long advocated to get Medicare lifetime coverage of immunosuppressants. Kidney organizations, renal professionals, and dialysis and transplant patients and their loved ones spent years writing letters, making phone calls, and meeting with legislators and their staff to lay the groundwork. Before December 21, 2020, Medicare coverage for immunosuppressants for transplant recipients was 36 months for all. The Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 extended lifetime coverage for those 65 and older. Those with Medicare due to disability who had Medicare Part A the month of their transplant and Part B when these drugs were ordered also got lifetime coverage. However, those under 65 had no help for these drugs. With the limited number of organs for transplant and the cost savings if Medicare pays for the transplant drugs, the case was strong to extend Medicare to cover these drugs for longer than just 36 months for those under 65 who are not disabled.
What Changes Are Coming in 2023?
Full benefit coverage under Medicare Part A and Part B still ends 36 months post-transplant for those with ESRD only. However, in 2020, the House and the Senate passed companion bills to extend Medicare Part B coverage for immunosuppressants ONLY for transplant recipients who:
Have—or will lose—Medicare coverage 36 months post-transplant and
Do not have other coverage through an individual or work plan, Medicaid, CHIP, or the VA any time they are eligible for this benefit.
President Trump signed this into law on December 27, 2020. Extension of Medicare Part B for immunosuppressants was included in the $2.3 trillion bill for COVID-19 relief and government funding. The law is 2,124 pages long. Section 402 on pages 1,817-1,821 of the PDF describes this new single benefit. Keep in mind that those who qualify for this benefit will have no other Medicare Part A or B coverage. So, they will still need another health plan. Those who obtain other coverage must let Medicare know within 60 days.
Those who had Medicare Part A but lost it 36 months post-transplant and have no other coverage can enroll in this limited Medicare Part B benefit starting October 1, 2022. Their coverage will start January 1, 2023. Someone who loses Medicare Part A after 36 months post-transplant on or after January 1, 2023 and have no other coverage will be deemed enrolled and their coverage will start the first of the month when they lose Part A due to transplant.
How Much Will This Cost Patients?
There will be a premium of 15% of the monthly actuarial rate for Medicare for those age 65. This amount changes yearly. In November 2020, the Federal Register published the monthly Part B actuarial rate for those age 65 and the disabled, Part B premium and deductible amounts for 2021.
- The monthly actuarial rate for Medicare in 2021 is $291.
- The monthly premium for full Part B in 2021 is 50% of the $291 ($145.50) plus a $3 repayment amount required by law or $148.50. This benefit is only for Part B coverage of immunosuppressants. So, the premium will be 15% instead of 50% of the monthly actuarial rate.
- The monthly actuarial rate for Medicare for those 65 will be published in October 2022, and 15% of that could be around $50 a month. Those who qualify for Medicare Savings Programs due to low income and assets will be able to get help to pay the premiums and/or 20% coinsurance for this drug benefit.
Where Can I Learn More?
As this change will not take place until 2023, little is published yet except the law itself. Medicare will likely include information online and in its booklets about coverage. One booklet where it is likely to be described is Medicare Coverage for Kidney Dialysis and Kidney Transplant Services, which is updated yearly. The Kidney School module on Paying for Dialysis and Transplant will also be revised to include information about this benefit when we know what the premium will be.
Page TF Woodward RS. Cost–effectiveness of Medicare’s coverage of immunosuppression medications for kidney transplant recipients, Expert Review of Pharmacoeconomics & Outcomes Research, 9:5, 435-444, 2009.↩
United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020. https://adr.usrds.org/2020/reference-tables (K.12, K.b, K.6)↩