Medicare Part B Immunosuppressive Drug Benefit
Patients with Medicare because of ESRD currently lose coverage 36 months after a kidney transplant unless otherwise eligible for Medicare. Patients who meet certain criteria will be able to qualify for continuous Medicare-covered immunosuppressive drugs. This new benefit is called Medicare Part B Immunosuppressive Drug (Part B-ID). It only covers immunosuppressive drugs and no other items or services.
Who's Eligible to Enroll?
Patients who meet these criteria are eligible for Part B-ID coverage:
- Currently or previously had Medicare because of ESRD that ends 36 months after a kidney transplant
- Attest that they aren’t currently enrolled in other health coverage and don’t expect to enroll in other health coverage that would make them not eligible for Part B-ID
Who Isn’t Eligible to Enroll?
Patients who have other certain health coverage aren’t eligible to enroll in Part B-ID. Other health coverage includes:
- Group or individual health plans (including Marketplace plans) or National Health Plans
- Medicaid or the Children’s Health Insurance Program (CHIP) coverage that includes immunosuppressive drug coverage
- Department of Veterans Affairs (VA) coverage or eligible to get immunosuppressive drugs from the VA
When Can an Eligible Patient Enroll?
Eligible patients can apply for the Part B-ID benefit starting October 1, 2022. After this time, an eligible patient can enroll or disenroll at any time, without penalty.
When Does Coverage Start?
Coverage for eligible patients can start as early as January 1, 2023, if they sign up by December 31, 2022. If a patient signs up after December 31, 2022, their coverage will start the month following the month in which they 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?
Patients enrolled in Part B-ID can’t have other coverage for immunosuppressive drugs. If a patient enrolls in Part B-ID, but later gets other coverage, they must end their Part B-ID enrollment by notifying Social Security within 60 days of enrolling in new coverage. If a patient loses their other coverage, they can apply for Part B-ID.
Certain patients with low-income enrolled in Part B-ID 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 their Part B-ID premiums and coinsurance.
What Are the Out-of-Pocket Costs?
The patient’s annual Part B deductible and 20% coinsurance apply.
How Can I Help My Patients Enroll?
If your patients meet the criteria above, encourage them to enroll by calling Social Security at 1-877-465-0355. TTY users can call 1-800-325-0788.
What Else Do I Need to Know?
- View the ESRD coverage ending letter, which patients will get when their ESRD coverage with Medicare is about to end
- View the Checking Medicare Eligibility (PDF) to help your patients and prepare accurate claims
- Your patients will get a new Medicare card that shows they’re eligible for Part B-ID benefits