Editor's note: this blog post has since been updated.
In December 2020, an important piece of legislation was signed into law giving kidney transplant recipients under the age of 65 immunosuppressive drug, or antirejection medicine, coverage for the life of their transplant through Medicare. Here are some answers to commonly asked questions about this new law, when it kicks in, who qualifies, when to enroll and more.
What is the current law?
Most people with kidney failure are eligible for Medicare three months after starting dialysis, regardless of their age. If you are under age 65, Medicare coverage ends 36 months after you receive a kidney transplant, meaning coverage for your immunosuppressive drugs, which you need to keep your body from rejecting your transplanted kidney, ends at that time as well.
The end of Medicare coverage has had disastrous results for people with kidney transplants who cannot afford the medicines on their own. Patients have lost their transplants, forcing them to return to dialysis, and in some cases patients have died.
What is changing?
Starting January 1, 2023, if you are under age 65, are living with a kidney transplant and meet other criteria, you will be eligible for Medicare coverage of your immunosuppressive drugs for the life of your transplant. The Department of Health and Human Services (HHS) will draft regulations on how this change will be implemented.
Who will be eligible for the benefit?
If you are a kidney transplant recipient under age 65 and were enrolled in Medicare or applied for Medicare coverage prior to your kidney transplant, you are eligible. You must have also received your transplant at a Medicare-certified transplant center.
The benefit will be an insurance of last resort, meaning that if you have any other insurance, that insurance, rather than Medicare, must be used to pay for the medicine. Other types of insurance include: Medicaid, qualified health plans purchased through the Affordable Care Act's Marketplace or Exchanges, employer group health plans, individual insurance, TRICARE, the State Child Health Insurance Program, and Veterans Affairs benefits.
Does the new law include other drug coverage or health benefits in addition to immunosuppressive drug coverage?
No, the benefit will be for immunosuppressive drugs only.
Do I have to enroll in the prescription drug benefit under Medicare (Medicare Part D)?
No, this benefit will be provided under Medicare Part B, which covers outpatient services in the Medicare program.
How do I enroll for this new coverage?
HHS is now writing regulations to implement the law, and the regulations will include instructions on how to enroll. You will be asked to sign and send to the Commissioner of the Social Security Administration an attestation, or proof, that you do not have access to an alternative insurance plan.
The open enrollment period for the immunosuppressive drug coverage will begin on October 1, 2022.
How much will it cost?
Each year, the Secretary of HHS determines the Part B premium for Medicare beneficiaries age 65 and older. If you are eligible for this immunosuppressive drug coverage, you will be required to pay 15% of the Medicare Part B premium for Medicare beneficiaries over the age of 65.
Will I be required to use specific drugs or generics?
No, you can use the medicine you are currently using. There will be no step-therapy or drugs from specific drug tiers that you must use.
I had private insurance when I received my transplant and never enrolled in or applied for Medicare. I have now lost my job and need help paying for my immunosuppressive drugs. Am I eligible for this benefit?
No, only those who were enrolled in or applied for coverage prior to their transplant are eligible for this benefit.