CMS releases final rule for expanded immunosuppressive drug coverage
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Patients with a kidney transplant who are younger than 65 years qualify for expanded immunosuppressive drug coverage starting Jan. 1, 2023.
CMS has released final regulations for the Medicare benefit, called the Part B-ID and based on the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act passed by Congress in 2020.
It offers lifetime coverage of immunosuppressive drugs for patients younger than 65 years who currently lose Medicare coverage 3 years after a kidney transplant. The expanded coverage begins after the 36-month benefit expires but is for immunosuppressive drugs only, unless a patient qualifies for Medicare based on age or disability.
Public support
“We received comments from patient advocates, associations, states, health plans and individuals offering broad support on our proposal to extend coverage of immunosuppressive drugs under Medicare Part B ... ,” HHS wrote in the final rule. “Many commenters expressed that this benefit was long-awaited and overdue, and they pointed out that the extended coverage of these drugs would help to prevent organ rejection in the post-transplant patient, and thus, will save lives and conserve Medicare resources.”
High cost
Currently, only patients older than 65 years with end-stage kidney disease qualify for lifetime coverage of immunosuppressive drugs.
“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,” the National Kidney Foundation said in a statement about the expanded benefit. “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.”
To qualify for the benefit, patients must receive the kidney transplant at a Medicare-approved facility and must attest that they do not have other public or private health insurance with an immunosuppressive drug benefit, including Medicaid. Enrollment is open for patients at any time.
According to the NKF, patients who chose the benefit after their 36 months of coverage ends will pay a monthly premium equal to 15% of the monthly rate for Medicare beneficiaries aged 65 years and older. The amount will be adjusted each year. For 2023, the monthly premium for the immunosuppressive benefit will be $97.10, which equals 15% of the combined individual and HHS portion of the full Part B benefit. Patients will also have a 20% co-pay for the medication benefit, according to the NKF.
Patients may qualify for assistance to help pay the monthly premiums and cost-sharing. More information on enrolling and qualifying for the coverage can be obtained at the Social Security Administration at 877-465-0355.
References:
- Frequently asked questions about the expanded Medicare coverage for immunosuppressive drugs for kidney transplant. www.kidney.org/atoz/content/faq-expanded-medicare-coverage-immunosuppressive-drugs-kidney-transplant-recipients. Accessed Dec. 13, 2022.
- Medicare Program; Implementing certain provisions of the Consolidated Appropriations Act, 2021 and other revisions to Medicare enrollment and eligibility rules www.federalregister.gov/documents/2022/11/03/2022-23407/medicare-program-implementing-certain-provisions-of-the-consolidated-appropriations-act-2021-and. Accessed Dec. 13, 2022.
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