Medicare Partial Part B Benefit for Immunosuppressive Drugs (Part B-ID)

Eligibility, Coverage, and Costs

Fact checked by Nick Blackmer

You can qualify for Medicare if you have end-stage renal disease (ESRD), meaning you have kidney disease serious enough to require dialysis or a kidney transplant. Until recently, that coverage ended 36 months after a successful kidney transplant. With a functional kidney, Medicare no longer saw you as having a life-threatening condition.

That policy left many transplant recipients without the essential care they needed. Specifically, regardless of the type, people who have had a transplant need to take immunosuppressive drugs to prevent their bodies from rejecting their new organ. These medications need to be taken for the rest of their lives.

The Centers for Medicare and Medicaid Services has finally addressed this gap in care. Starting in 2023, Medicare offered a new Part B benefit for immunosuppressive drugs, known as Part B-ID, for people who have had kidney transplants but who would not otherwise qualify for Medicare.

Qualifying for ESRD Medicare

To be eligible for Original Medicare, you mustbe 65 or older or have a qualifying disability. You must also meet residency requirements. Specifically, you (or your spouse) would need to be a U.S. citizen, a legal permanent resident (i.e., a Green Card holder), or a legally documented immigrant.

Legal Immigrants

Not all documented immigrants qualify for Medicare. They must have a work history that shows they paid a sufficient amount of Medicare and Social Security taxes.

Eligibility for ESRD Medicare (Medicare for people with end-stage renal disease) is a bit different. Having ESRD and being a U.S. citizen is not enough. You, your spouse, or your parent/guardian (if you are a child) must also qualify for Social Security Insurance (SSI), Social Security Disability Insurance (SSDI), or Railroad Retirement Board (RRB) benefits.

Understanding Medicare Benefits

Once you qualify for ESRD Medicare, you have access to the same benefits as people on traditional Medicare:

• Medicare Part A (hospital insurance): Part A covers the care you receive when you are admitted as an inpatient to the hospital, including a kidney transplant. It also covers short-term care in a skilled nursing facility (SNF) after your hospital admission, certain home health services, and hospice care. This part of Original Medicare, so-called because it was first created in 1965, is run by the federal government.

• Medicare Part B (medical insurance): Part B covers care you receive outside of the hospital, such as office visits, diabetic supplies, laboratory tests, imaging studies, procedures, physical and occupational therapy, limited medications (including immunosuppressive drugs), certain vaccinations, etc. It also includes care you receive in urgent care clinics, an emergency room, and the hospital when you are placed under observation. Like Part A, it is also part of Original Medicare and managed by the government.

• Medicare Part C (Medicare Advantage): Run by private insurance companies, this alternative to Original Medicare covers everything that Part A and Part B do and can also offer extended drug coverage and/or supplemental benefits.

• Medicare Part D: Part D provides extended coverage for prescription drugs, vaccinations, and diabetic supplies. These plans are run by private insurance companies and can be used with Original Medicare or a Medicare Advantage plan (if the Medicare Advantage plan does not include drug coverage).

If you have a successful kidney transplant while on ESRD Medicare, your benefits will end 36 months after the surgery unless your situation changes and you qualify for Medicare based on age or another qualifying medical condition.

Who Qualifies for Part B-ID

Starting on January 1, 2023, people who had a kidney transplant while they were on ESRD Medicare may be able to get Part B coverage for their immunosuppressive drugs beyond 36 months.

No other Part B benefits will be covered. They will also not be eligible for Part A, Medicare Advantage, or Part D benefits.

To qualify, the following conditions must be met:

• They had a kidney transplant that was covered by Part A.

• They do not currently have other health coverage that covers immunosuppressive drugs. This includes, but is not limited to, Medicaid, the Children’s Health Insurance Program (CHIP), TRICARE, or Department of Veterans Affairs (VA) health benefits.

Retroactive Medicare Coverage

If you did not have Part A benefits at the time of your kidney transplant, don’t worry. You can retroactively enroll in Part A within 12 months of your surgery. In that case, you may still be eligible for Part B-ID.

The change is not only good for recipients—it will save Medicare millions every year. According to the Department of Health and Human Services, extending coverage for immunosuppressive drugs will not only prevent transplants from failing. It will prevent recipients from going back on ESRD Medicare for dialysis or another transplant.

Within five years, Medicare will start to save more than it invested in the extended drug coverage. Within 10 years, it will save more than $129 million per year.

Enrollment in Part B-ID

You can enroll in Part B-ID any time after a kidney transplant, even if you are currently on ESRD Medicare. However, signing up for the full Part B benefit is more advantageous while you still qualify for ESRD Medicare. However, some people may choose the Part B-ID benefit instead to keep costs down. Part B-ID coverage begins the month after you sign up.

Medicare Savings Programs

If you have a hard time affording your monthly Part B premiums, deductibles, and/or coinsurance, a Medicare Savings Program could help. Depending on your current income and assets, you may qualify for one. Reach out to your local Medicaid office to learn more.

If you get other health insurance that covers immunosuppressive drugs, you will no longer be eligible for Part B-ID. You must notify Social Security within 60 days accordingly. You can enroll in Part B-ID again in the future if you lose that other insurance coverage for any reason.

How Much Part B-ID Costs

You will pay a monthly premium whether you get the full Part B benefit or the partial Part B benefit for immunosuppressive drugs (Part B-ID). What you pay is based on your marital status and income taxes from two years ago, i.e., your 2022 taxes set your 2024 premium rates. Monthly rates change every year.

You will also be responsible for paying an annual deductible ($226 in 2023) and a 20% coinsurance for the cost of your medications.

Summary

The partial Part B benefit for immunosuppressive drugs (Part B-ID) is a new offering from CMS that extends coverage for people currently or previously on ESRD Medicare. If you have had a kidney transplant that Medicare covered, you may now qualify for coverage of your immunosuppressive medications even after your ESRD Medicare benefits expire.

Frequently Asked Questions

How many people have kidney transplants every year?

In 2022, more than 26,300 people had a kidney transplant in the United States. That same year, nearly 46,000 people were on the waiting list for one.

How much do immunosuppressive drugs cost?

There are generic versions of many common immunosuppressant medications. Even though they can be less expensive, out-of-pocket costs can still be high. According to GoodRx, CellCept (mycophenolate) and Prograf (tacrolimus), two of the most commonly used anti-rejection medications after a kidney transplant, cost $8 to $129 per month and $46 to $73 per month, respectively. Many people will be on more than one immunosuppressive drug.

Will the new Part B benefit (Part B-ID) pay for office visits and other care I need to monitor my kidney transplant?

No. The new partial Part B-ID benefit provides coverage for immunosuppressive drugs only. Other services usually covered by Part B are not included.

Read the original article on Verywell Health.