Medicare And Medicare Supplement Insurance Coverage For Esrd Treatments
Medicare Part A and Part B provide different dialysis and transplant-related coverage. Medicare Part A provides inpatient hospital care coverage and Medicare Part B provides medical care coverage.
Medicare Supplement insurance coverage will help you pay for some of the out-of-pocket costs associated with that coverage. This may be important to you if you use dialysis, since it will help pay for all of Medicare Part B co-payments that are required for most dialysis-related services.
Faq: New Medicare Coverage Of Immunosuppressive Drugs For Individuals With Kidney Transplants:
TopicsMedicare
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 will draft regulations on how this change will be implemented.
The open enrollment period for the immunosuppressive drug coverage will begin on October 1, 2022.
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Does Medicare Cover Dialysis
by Christian Worstell | Published December 16, 2020 | Reviewed by John Krahnert
In most cases, Medicare Part A does cover dialysis in a Medicare-approved hospital. Medicare Part B covers outpatient dialysis treatment, supplies and doctor visits.
A Medicare Supplement plan can help cover dialysis costs such as Medicare deductibles, copays, coinsurance and more.
You may be able to apply for Medigap plans in some states if you have ESRD, but insurance companies aren’t required to sell Medigap plans to beneficiaries under age 65 in all states.
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Does Medicare Part A And Part B Cover Kidney Transplant Surgery
The medical expenses involved in a kidney transplant can be extensive and you will need medical care before and after your surgery. Medicare generally covers you for all stages of your kidney transplant. If you have a living donor, generally Medicare will cover his medical expenses involved with organ donation as well. Medicare Part A and Medicare Part B generally cover different expenses involved in a kidney transplant.
Medicare Part A coverage of kidney transplants typically includes:
- Kidney registry fee
- Kidney procurement if theres no kidney donor
- Tests, labs and exams prior to surgery including tests needed to evaluate potential kidney donors
- Inpatient services in a Medicare-certified hospital
- Follow-up care after the kidney transplant
- Full cost of care of your kidney donor if you have a living donor
- Blood
Medicare Part B coverage of a kidney transplant typically includes:
- Immunosuppressive prescription drugs that lower the bodys ability to reject the kidney transplant
- Doctors care for all stages of the kidney transplant surgery
- Doctors care for your donor during his hospital stay
- Blood
- Follow-up care after the kidney transplant
Medicare Part B coverage of immunosuppressive prescription drugs is generally for a limited time after you leave the hospital following a kidney transplant. For long-term coverage of immunosuppressive prescription drugs you may need Medicare Part D coverage.
What Other State Programs Can Help
Medicare Savings Programs are programs in which your state may pay your Medicare premiums, deductibles, and/or coinsurance if you have a low income and few assets. How Medicaid works in U.S. territories varies. Learn more about how your state Medicaid works online.
State Health Insurance Assistance Programs give local advice about health insurance to people who have Medicare or who are eligible for Medicare. SHIP counselors can help you choose the best plan for your needs. Find a SHIP counselor at shiptacenter.org or call 1-877-839-2675.
State kidney programs provide financial help and other services to people with kidney disease. Talk with your dialysis or transplant clinic social worker or financial counselor to find out if your state has a kidney program.
State Pharmaceutical Assistance Programs help pay for prescription medicines in certain states. Learn whats available in your state with the SPAP online locator.
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Has The Aca Expanded Medicares Immunosuppressive Drug Coverage For Kidney Transplant Recipients
I had a conversation with my doctor last week. . He asked me if I had heard anything during my last trip to Washington, D.C. about an extension of coverage through the ACA to kidney transplant patients of the immunosuppressive drug coverage beyond the 36 month period that currently exists. This rang a bell in the back of my brain, so I decided to check it out.
Every transplant patient or transplant candidate knows the current status of the law. If you are a kidney transplant recipient, you must take medications the rest of your life to prevent rejection of your transplanted kidney. Medicare pays for the transplant and immunosuppressive drugs for 36 months post-transplant, but coverage of these critical medications stops unless the beneficiary is Medicare-aged or Medicare-disabled. Here is where the gap in coverage comes in if youre under 65 and you have received a transplant, you are not age-eligible, nor are you considered disabled because after you have a transplant, you are no longer Medicare-disabled. Coverage for anti-rejection drugs for those patients that fall into the gap is limited to 36 months. The catch is that anti-rejection meds are very expensive. One newspaper article I read reports that one patient was paying as much as $1,750 a month, and the National Kidney Foundation estimates that Medicare pays $124,643 for a first year transplant patient, and then pays $24,612 a year primarily for anti-rejection meds thereafter.
Does Medicare Cover Travel Expenses For Transplants
Original Medicare covers travel and lodging only for Medicare-approved organ transplants when the Medicare Advantage plan chooses to provide services at a Medicare-approved transplant facility at a distant location that is farther away than the normal community pattern of care for transplant services.
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What Other Federal Programs Can Help
The Social Security Administration can provide financial help through two programsSocial Security Disability Insurance and Supplemental Security Income .
- SSDI pays a monthly amount to people who cant work and have paid enough Social Security taxes. If you have an illness or injury that Social Security believes will keep you out of work for at least a year, SSDI payments may be an option. There is a 5-month waiting period before SSDI payments begin.
- SSI pays a monthly amount to disabled children and adults who earn little and dont have many financial assets. A person who gets SSI may be able to get food stamps and Medicaid, too.
Read more about both SSDI and SSI and learn how to apply at SSA.gov or by calling 1-800-772-1213 .
What Are The Extra Costs
According to the American Kidney Fund, the patients have to take anti-rejection drugs for the rest of their lives, and this will cost around $17,500 per year.
In the unfortunate situation of a transplant failure, the recovery treatment cost could go up to hundreds of thousands of dollars. For instance, the Center for Medicare & Medicaid Services says that the cost of treatment after a transplant failure, also known as graft failure, will be around $142,000. Around 55% of kidney transplants fail within ten years.
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How Much Does Medicare Pay For Organ Transplants
Between doctors visits, laboratory testing, surgery, and more, organ transplantation is quite expensive.
According to a 2020 research report of transplant costs in the United States, the average costs for organ transplants include:
- $1,664,800 for a heart transplant
- $1,295,900 for a double lung transplant or $929,600 for a single lung transplant
- $1,240,700 for an intestine transplant
- $878,400 for a liver transplant
- $442,500 for a kidney transplant
- $408,800 for a pancreas transplant
Medicare pays for most services and costs associated with Medicare-approved organ transplants. Services include:
- pretransplant services
- follow-up services
- immunosuppressant and other necessary prescription drugs, in some cases
Medicare also pays for all costs related to finding a donated organ and all medical care for the organ donor, such as doctors visits, surgery, and other necessary medical services.
While Medicare covers almost all organ transplantation costs, youll still owe out-of-pocket costs for your services.
Renal Disease Treatment Coverage Provided By Medicare
While Medicare does not cover transportation to dialysis, it generally provides coverage for certain treatments, medications and kidney transplant procedures. Transplant services covered by Medicare Part A include:
- Kidney registry fee
- Expenses of finding appropriate kidneys for transplant when donors are not available
- Complete care costs for kidney donors
- Inpatient services at Medicare-certified hospitals
Transplant services included by Medicare Part B include:
- Doctor’s services before, during and after kidney transplant surgery procedures
- Immunosuppressive transplant drugs
- Blood transfusions
Recipients on Original Medicare plans may receive coverage for dialysis in-hospital and at Medicare-certified dialysis facilities. Plans may also cover the costs of dialysis equipment for at-home use.
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Eligibility For Part C
Starting in 2021, people with ESRD are eligible to enroll in a broader range of Medicare Advantage plans.
If you want to switch from original Medicare to a Medicare Advantage plan, you will be able to do so during the annual open enrollment period, which takes place from .
If you currently have a Medicare Advantage Special Needs Plan but want to switch to a different type of plan, you can do this during Medicare Advantage open enrollmentfrom .
How Long Does Medicare Last After A Kidney Transplant
If you are a Medicare beneficiary suffering from End-Stage Renal Disease or kidney failure, you should keep the following information in mind regarding a kidney transplant.
- If you only became eligible for Medicare because of kidney failure, your Medicare coverage will end 36 months after your kidney transplant.
- Medicare will only cover your kidney transplant if its performed in a hospital that is Medicare-certified to do kidney transplants.
- Medicare will continue to cover your transplant drugs with no time limit if you were already eligible for Medicare before you were diagnosed with kidney failure. Your Medicare coverage of immunosuppressive drugs will also continue without a time limit if you became eligible for Medicare due to age or other disability after the transplant took place or if you had private insurance that paid primary to your Part A coverage.
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When Does Medicare Cover Organ Transplants
Medicare covers medically necessary services related to the prevention, diagnosis, and treatment of health conditions.
While Medicare doesnt set any criteria for covered organ transplants, organ transplant programs generally do have eligibility requirements.
Once a doctor has determined that a Medicare beneficiary requires an organ transplant, Medicare will cover the following transplants:
Medicare covers only transplants performed through Medicare-approved transplant programs. These approved organ transplant programs must exist within hospitals that are contracted to provide services under Medicare.
The only exception to this rule is that cornea and stem cell transplants dont need to be performed in a Medicare-approved transplant center.
Are Immunosuppressive Drugs Covered By Medicare
Immunosuppressive drugs are covered by Medicare for various medical reasons, such as:
- To stop the body from rejecting donor organs
- To treat autoimmune conditions, such as:
- Lupus
- Crohns disease
- Alopecia areata
There are several types of immunosuppressive drugs. Some are taken orally, and others are given via infusion or injection. You may need to take one or more every day.
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Kidney Transplant And End
If a Medicare beneficiary has Medicare due to ESRD, there are some specific rules that apply. First, Medicare covers those with end-stage renal disease that needs a pancreas transplant if either of the following is true:
-
They must have previously had a kidney transplant
-
The surgeon performs a kidney transplant at the same time as the pancreas transplant
Its important to know that Medicare coverage usually ends for those with ESRD 36 months after they receive a kidney transplant. However, Medicare will pay for immunosuppressive drugs indefinitely so long as the patient becomes eligible for Medicare because of age or disability prior to their ESRD diagnosis OR following a kidney transplant in a Medicare-approved facility.
Note: Learn more about ESRD and Medicare at this resource.
If My Coverage Expires Prior To January 1 2023 Will I Be Eligible
Yes. Anyone who had a transplant and whose Medicare eligibility expires before, on, or after January 1, 2023 can enroll in Medicare Part B solely for immunosuppressive coverage if they do not have other insurance for their immunosuppressive drugs. The enrollment period for anyone whose Medicare coverage ends prior to January 1, 2023 begins on October 1, 2022.
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Does Medicare Advantage Cover Liver Transplants
Medicare Part C, more commonly known as Medicare Advantage, allows beneficiaries to purchase private health insurance plans that combine their Parts A and B benefits into a single policy.
With the exception of hospice care, which is still provided through Part A, Medicare Advantage plans must provide the same coverage you get with Original Medicare. They are not limited to this coverage, though, and most Advantage plans provide additional benefits as well. The most common is prescription drug coverage, found in around 90 percent of Part C plans. Other common extras are routine eye exams, routine dental care, hearing aids, and fitness programs.
Working under the guidelines set by the Centers for Medicare & Medicaid Services , private insurance companies provide Advantage plans. This is why costs vary depending on which insurance company and Advantage plan you choose. You still owe the Part B premium, though.
Other out-of-pocket costs are similar to Original Medicare and may include deductibles, copays, and monthly premiums. For specifics, please refer to your plan provider.
What Is The Kidney Transplant Cost
According to the actuarial company Milliman, the estimated U.S. average billed charges for a kidney transplant in 2017 was $414,800.
- Under Medicare, you may pay nothing for a living donor for a kidney transplant.
- You pay 20% of the Medicare-approved amount for doctors services and the Part B deductible applies
- You pay various amounts for transplant facility charges, such as an inpatient hospital stay copayment
- You may pay nothing for Medicare-certified laboratory tests.
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How Much Does A Kidney Transplant Cost
In most cases, kidney transplant surgeries are covered by health insurance policies. If you have health insurance then you will have to pay the doctor visit, lab exams, and prescription medicine out of your pocket, plus the coinsurance of 10% to 50% for surgery and other procedures. All of these could reach the yearly out-of-pocket maximum.
In case you dont have health insurance you will have to pay around $262,000 or even more for a kidney transplant, including the costs of donor matching, pre-transplant screening, the surgery itself, care after surgery, and the drugs needed in the first six months after surgery. After that, the anti-rejection drugs will cost you around $17,500 per year.
From Vimo.com, a website that compares the costs of health care, we find out that the average cost of a kidney transplant is around $144,000 and if it is negotiated through a health insurance company, it will be around $34,000.
Transplant Living website states that the total expenses with a kidney transplant starting from the month before surgery until the end of the first six months post-surgery will be around $262,000, including more than $17,500 for medication. These expenses include the costs of the pre-surgery medical examinations, the surgery itself, hospitalization for any complications, care after surgery, and the anti-rejection medicine.
You might also like our articles about the cost of the actual kidney, a liver transplant, or heart surgery.
An Enormous Win For Patients Saving Millions Of Dollars For Medicare
The action won wide praise from the clinical community.
“This bipartisan, common-sense policy will directly improve the lives of hundreds of transplant patients and help increase the number of transplants available to patients,” said Anupam Agarwal, MD, president of the American Society of Nephrology , in a written statement.
“The bill’s passage represents an enormous win for patients and the fulfillment of a top ASN priority. The society stands ready to work with policy makers to implement this legislation,” he said.
Michelle Josephson, MD, chair of the ASN Policy and Advocacy Committee, added: “I am thrilled to see this critical legislation pass Congress. I have cared for too many patients who have lost their kidney transplants because they could not afford their immunosuppressive medications after Medicare ceased coverage at 36 months, only to return to more-expensive dialysis.”
And Marwan S. Abouljoud, MD, president of the American Society of Transplant Surgeons, noted in a separate statement: “Medicare’s limitation on immunosuppressive drug coverage was never able to be justified medically, economically or ethically, and I am thankful Congress has finally taken action on this much-needed reform.”
The new law specifies that Medicare will cover the cost of immunosuppressive drugs indefinitely if no other coverage is available.
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