In the past, people on Medicare due to kidney failure, or end stage renal disease (ESRD) were eligible for 36 months of Medicare coverage after a successful kidney transplant. This coverage was crucial in large part for the payment of the hugely expensive immunosuppressive drugs necessary to prevent rejection of the transplanted kidney and keep it functioning well. Yet, unless a person was otherwise eligible for Medicare due to age or disability, this essential coverage would end in 36 months. This loss of coverage caused people huge financial strain, costing $10,000-$17,000 a year for the medication, often leading people to ration or stop taking the medications entirely, either of which greatly increased 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.
Yet, as of January 1, 2023, that has all changed. Now, those who meet certain criteria, can qualify for lifetime Medicare coverage for these immunosuppressive drugs, regardless of age. This is great news!
The new benefit is called Medicare Part B Immunosuppressive Drug (Part B-ID) and has a monthly premium of $97.10 in 2023. It only covers immunosuppressive drugs and no other items or services.
Who is eligible for the lifetime Part B-ID coverage?
Anyone who meets the following criteria is eligible for continuous 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 (Medi-Cal in California).
- Medicare coverage under Part A has ended.
- Does not have other public or private health insurance with an immunosuppressive benefit.
Public insurance includes Medicaid (Medi-Cal), 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. Remember that the Part B-ID benefit extends Medicare only for immunosuppressive drug coverage. The forms of health insurance listed above 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 can I get the expanded immunosuppressive drug coverage?
The expanded eligibility became effective as of January 1, 2023 and enrollment began as early as October 1, 2022 for kidney transplant recipients whose Medicare has ended. Kidney transplant recipients whose Medicare entitlement ends 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).
Below are some additional frequently asked questions on Medicare’s Part B-ID from the Centers for Medicare and Medicaid Services (CMS).
When Does Coverage Start?
Coverage can start as early as January 1, 2023, if you signed up by December 31, 2022. If you sign up after December 31, 2022, your coverage will start the month following the month in which you sign up.
The Part B-ID benefit covers continuous immunosuppressive drugs, which are medically necessary for preventing or treating the rejection of a transplanted organ or tissue. These drugs suppress a patient’s natural immune responses.
What’s Not Covered?
The Part B-ID benefit doesn’t cover any other Part A, Part B, or Part D services, supplies, or medications. It doesn’t cover drugs that treat conditions that may result from an immunosuppressive drug regimen, like antibiotics, vitamins, and other drugs not directly related to organ rejection.
How Does It Work with Other Insurance?
To be enrolled in Part B-ID, you can’t have other coverage for immunosuppressive drugs. If you enroll in Part B-ID, but later get other coverage, you must end your Part B-ID enrollment by notifying Social Security within 60 days of enrolling in new coverage. If you lose your other coverage, you can apply for Part B-ID.
If you are enrolled in Part B-ID and have low-income, you may also be eligible for Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or Qualifying Individuals (QI) Medicare Savings Programs (MSPs) to pay some or all your Part B-ID premiums and coinsurance.
What Are the Out-of-Pocket Costs?
Your annual Part B deductible and 20% coinsurance apply. Note that with just this coverage (Part B-ID), you cannot get a Medigap policy to cover the 20% coinsurance.
What Else Do I Need to Know?
- View the ESRD coverage ending letter, which you will get when your ESRD coverage with Medicare is about to end
- View the Checking Medicare Eligibility (PDF) to help prepare accurate claims
- You will get a new Medicare card that shows you’re eligible for Part B-ID benefits
Where Can I Get More Information?
- Final rule
- Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and other Revisions to Medicare Enrollment and Eligibility Rules
- MLN Matters® Article: New Medicare Part B Immunosuppressant Drug Benefit (MM12804)
- National Kidney Foundation article, Expanded Medicare Coverage of Immunosuppressant Drugs for Kidney Transplant Recipients