Starting on January 1, 2023, immunosuppressive drug coverage had a time limit for the length of time that beneficiaries could stay on Medicare if they were under 65. This immunosuppressive coverage typically occurs when someone meets the Medicare requirements for Medicare due to needing a kidney transplant due to end-stage renal disease (ESRD).
Below we’ll discuss the new rules and explain who can get coverage for immunosuppressive drug coverage and how long they’ll keep it.
Expanded Immunosuppressive Drug Coverage Under Medicare Part B Explained
At the end of 2020, congress passed the kidney transplant patients act to help kidney transplant recipients maintain Medicare coverage for immunosuppressive drugs. Until January of 2023, these Medicare beneficiaries would only be able to stay with Medicare health care for 36 months after an organ transplant.
Because of the high cost of these prescription drugs, many would ration the medication or stop taking it altogether. Failure to take the medicines properly would typically lead to a failed kidney transplant.
Other transplants that can qualify for a coverage extension include:
- Heart, kidney, bone marrow (stem cell), liver, or lung transplant
- Whole organ pancreas transplant performed accompanying with or after a kidney transplant due to diabetic nephropathy (after July 1, 1999)
- Intestinal transplant (on or after April 1, 2001)
Part B Immunosuppressive Drug Coverage Only Chart
Below is the Income Related Monthly Adjusted Amount (IRMAA) for Medicare beneficiaries enrolled in immunosuppressive drug-only Medicare Part B coverage. This chart will show how much the Medicare Part B premium will be for single or married beneficiaries filing jointly.
|Beneficiaries who file individual tax returns with modified adjusted gross income:||Beneficiaries who file joint tax returns with modified adjusted gross income:||Income-Related Monthly Adjustment Amount||Total Monthly Premium Amount|
|Less than or equal to $97,000||Less than or equal to $194,000||$0.00||$97.10|
|Greater than $97,000 and less than or equal to $123,000||Greater than $194,000 and less than or equal to $246,000||$64.70||$161.80|
|Greater than $123,000 and less than or equal to $153,000||Greater than $246,000 and less than or equal to $306,000||$161.80||$258.90|
|Greater than $153,000 and less than or equal to $183,000||Greater than $306,000 and less than or equal to $366,000||$258.90||$356.00|
|Greater than $183,000 and less than $500,000||Greater than $366,000 and less than $750,000||$356.00||$453.10|
|Greater than or equal to $500,000||Greater than or equal to $750,000||$388.4||$485.50|
Premiums for high-income beneficiaries with immunosuppressive drug only Part B coverage who are married & file separately
For those high-income Medicare beneficiaries that are married and file their tax returns separately, the following chart shows what your IRMAA will be. These are for beneficiaries with Medicare Part B for immunosuppressive drug coverage only that are married and live with their spouse at any time throughout the year.
|Beneficiaries who are married and live with their spouses at any time during the year but who file separate tax returns from their spouses with modified adjusted gross income:||Income-Related Monthly Adjustment Amount||Total Monthly Premium Amount|
|Less than or equal to $97,000||$0.00||$97.10|
|Greater than $97,000 and less than $403,000||$356.00/td>||$453.10|
|Greater than or equal to $403,000||$388.40||$485.50|
Criteria for indefinite coverage for transplant immunosuppressive medications under Medicare Part B
As mentioned above, beneficiaries on Medicare due to ESRD and needing a transplant due to kidney disease would only qualify for Medicare coverage for 36 months after the transplant.
Effective January 2023, these beneficiaries could potentially stay on Medicare indefinitely if they meet the criteria listed below.
- The kidney transplant occurred in a Medicare-approved facility.
- The beneficiary is eligible for Medicare when the transplant happens.
- The beneficiary applied for Medicare before the transplant.
- They don’t have Medicaid coverage.
- They don’t have other private or public health insurance that covers immunosuppressive drugs.
Examples of public health insurance coverage include:
- Medicaid Services
- Veteran Affairs
Examples of Private insurance coverage include:
- Group health plans or Employer-sponsored plans
- Affordable Care Act family or individual plans<
- Standard Individual health insurance<
Will I be able to get extended immunosuppressive coverage?
Beneficiaries needing extended Medicare coverage of immunosuppressive drugs can extend ongoing coverage if they meet the criteria above. They must be able to qualify for Medicare eligibility based on ESRD kidney failure.
Suppose the beneficiary has no other health coverage, has an active Medicare entitlement for ESRD, and meets the continuous coverage for immunosuppressive drugs. In that case, Medicare could extend Part B coverage.
What if my coverage expires before January 1, 2023? Will I meet the criteria?
Any Medicare beneficiaries that lose their coverage on or before January 1, 2023, can apply to the Medicare Program for Part B comprehensive immunosuppressive drug coverage.
This extension is contingent on them meeting the requirements and criteria listed above. The enrollment period starts on October 1, 2022, for any beneficiaries whose coverage will expire on or before January 1, 2023.
Do I qualify for indefinite Medicare immunosuppressive coverage if I have both Medicare & Medicaid?
Coverage for indefinite Medicare immunosuppressive therapy is for beneficiaries that don’t have access to other health benefits or insurance.
If you already have Medicare and Medicaid and are on Medicare for other disabilities or are over 65, this wouldn’t apply to you. It wouldn’t apply because you already have Medicare Part A, Part B, and Medicaid to help pay for these costs.
If you’re under 65, only qualify for Medicare benefits due to kidney failure and dialysis, and are enrolled in Medicaid, you’ll not qualify for extended coverage. Your Medicaid drug benefit would be the health insurance used to pay for your immunosuppressive drugs.
After 36 months have passed since my transplant, will I continue to have other Medicare-covered benefits?
If you don’t have other insurance that provides an immunosuppressive therapy benefit and are eligible for Medicare due to kidney failure, it’s possible to get extended coverage.
To do so, you must have had the transplant completed in a medicare-approved facility and applied before the transplant. If you meet all the criteria, you can have the coverage extended.
You can’t receive extended benefits without other public or private health insurance. These include Medicaid, Affordable Care Act, VA, TRICARE, and group insurance coverage.
Does the extension cover other transplant-related medications?
Yes! The extended coverage would help with the costs of Medicare Part B covered immunosuppressive drugs.
These medications, such as cyclosporine, will help prevent transplant failure. Drugs that fall under the jurisdiction of Medicare Part D would require enrollment in a Medicare prescription drug plan.
Will I be charged the total Part B monthly premium with this expanded immunosuppressive drug coverage?
No, The full Medicare Part B premium is $164.90. If you’re only on Medicare for the immunosuppressive drug benefit, your premium will start at $97.10. Remember that higher-income Medicare beneficiaries could pay more based on their IRMAA.
Will the extension be limited to specific immunosuppressive generic drugs?
No! The nature of immunosuppressive therapy makes each patient’s needs different. Your provider will continue to prescribe the treatment that works for you.
Am I still required to pay the Part B coinsurance of 20% under Medicare Part B?
This information isn’t released yet. We anticipate the answer before January 1, 2023.
Is tacrolimus covered by Medicare Part B?
Yes! Medicare Part B can cover tacrolimus for immunosuppressive therapy. Tacrolimus is the most common drug for individuals recovering from an organ transplant.
Is Mycophenolate covered by Medicare Part B?
Mycophenolate is another common antirejection medication used for individuals with organ transplants. Medicare Part B covers Mycophenolate.
How To Get Supplemental Coverage for Part B Immunosuppressive Drugs
Most immunosuppressive medications fall under Medicare Part B coverage. This can become costly because of the 20% coinsurance and lack of a cap on what you can spend. Let our licensed insurance agents assist you with supplemental Medicare coverage to help cover these costs.
Simply call us at the number above, or fill out our online rate form. We’ll be glad to help find you coverage to provide peace of mind so you can focus on recovery.