Transplant recipients not eligible for Medicare Part B will have access to immunosuppressive and non-immunosuppressive drugs through the Medicare Part D program (if a plan in your region has a drug formulary that includes immunosuppressive drugs). In the event that a plan in your region has a drug formulary that includes immunosuppressive drugs, transplant recipients will still incur monthly premiums, a yearly deductible, as well as significant coverage limits.
Medicare is the federal health insurance plan for people over age 65 or who are long-term disabled. Eligibility and enrollment is through the Social Security Administration. Medicare has changed over the years, offering additional options for healthcare insurance. Traditional Medicare includes Part A for hospital insurance and Part B for medical coverage, meaning it covers doctor visits and other medical bills. Part C, also called Medicare Advantage, allows private health insurance companies to provide Medicare benefits. Part D is a prescription drug plan. It's important to carefully assess your healthcare needs and which plan is right for you. Learn more about Medicare benefits with expert advice from Sharecare.
1 AnswerFor transplant recipients the reality of utilizing Medicare Part D to maximize benefits is not simple, but rather complicated. The intricacies of Medicare Part D involve not only understanding premium costs and benefit stages, but formularies, and particularly for people having transplants, deciphering how Medicare Part B immunosuppressant coverage influences Part D coverage.
Medicare Part D plans are voluntary prescription drug coverage options offered by private insurance companies who meet standards established by Medicare. Everyone entitled to Medicare Part A (which covers inpatient care in hospitals, skilled nursing facilities, hospice care and some home health care) or enrolled in Medicare Part B (recipients pay a monthly premium for Part B, which helps cover doctor and specified outpatient care and some outpatient medications such as immunosuppressants for qualifying people) qualifies to enroll in a Part D plan.
Most Medicare recipients will pay a premium to participate in Part D, with premiums varying from plan to plan in each state. Part D plans’ monthly premiums range from less than $20 to greater than $60; however average premiums range from $32.20 to $37 for the average standard plan (Medicare defines standard plan as the minimum coverage that a drug plan most provide).
If you did not have Medicare Part A when you got your transplant or if you did not have your transplant in a Medicare approved transplant program, your anti-rejection drugs have not been covered by Part B, but may be covered under Part D.
1 AnswerListed below are two types of plans offering Medicare prescription drug coverage after a kidney transplant:
- Medicare Prescription Drug Plans: These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-For-Service (PFFS) Plans and Medicare Medical Savings Account (MSA) Plans.
- Medicare Advantage Plans (like an HMO or PPO) are other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.”
1 AnswerAfter a kidney transplant Medicare Part D can help you pay for your prescribed drugs that are not covered by Part A or Part B.
Medicare coverage for immunosuppressive drugs is often confusing because it is determined by a number of factors, including the transplant recipient’s Medicare eligibility at the time of transplant, disability status, whether the recipient received dialysis treatment, the type of organ being transplanted, and whether the transplant was performed in a Medicare-approved facility. Adding to the confusion is the Medicare Part D drug benefit, which provides additional drug coverage to many Medicare beneficiaries.
For Medicare beneficiaries who receive immunosuppressive coverage under Medicare Part B, non-immunosuppressive drug coverage can be accessible through enrollment in Medicare Part D.
1 AnswerQuestions you should ask when looking into Medicare Supplements for a transplant:
- Will this policy pay the hospital deductible?
- How expensive is this policy?
- Are there assistance programs to help purchase these plans?
- Can I be denied a Medicare Supplement policy?
1 AnswerQuestions you should ask about Medicare for a transplant include:
- How do I apply for Medicare?
- Is there a waiting period before I receive benefits?
- What happens if I’m denied Medicare?
- Will having savings accounts effect my qualifying for Medicare?
If you receive disability benefits (i.e., a Social Security disability benefits) you will automatically be enrolled in Medicare two years later.
Medicare does not cover 100% of charges in most situations. It is important to consider your options related to obtaining a Medicare Supplement or Medi-Gap policy.
1 AnswerMedicare will cover 80% of the cost of three immunosuppressant medications after a transplant.
If you receive Social Security Disability Income or are over the age of 65, your 80% Medicare coverage for these specific medications will be for the life of your transplanted organ.
If you receive Medicare benefits primarily due to your end-stage renal disease, the 80% Medicare coverage for these medications will be expected to terminate at the end of three years after transplant.
If you have another disabling condition that is documented and validated by Social Security and Medicare, it is likely your Medicare benefits will remain intact.
1 AnswerEvery year, even before the healthcare law, insurance companies that offered Medicare Advantage plans made decisions about what they would cover and what they would charge. Each insurance company will continue to make a business decision whether to change your benefit package and costs.
As in previous years, you will receive a notice from your Medicare Advantage plan in the fall. It will tell you what changes, if any, will take place in your plan for the upcoming year. This is the time for you to review your options carefully and make the best choice to fit your needs.
If you have questions about the notice, you can contact your Medicare Advantage plan directly. You can also call 1-800-Medicare (1-800-633-4227) to speak with a representative about your options.
You can also compare your options at Medicare Plan Finder: www.medicare.gov/find-a-plan. This site shows which Medicare Advantage plans are offered in your area.
If your plan is changed or dropped, you can switch to another available Medicare Advantage plan or to Original Medicare during Medicare’s open enrollment period.
1 AnswerYou should use Medicare’s open enrollment as an opportunity to review all your Medicare choices to select a plan that works best for you. Open enrollment is available each year between October 15 and December 7.
When evaluating different plans, remember to consider:
- Cost: What are the monthly premiums, the annual deductible and copays?
- Coverage: What services are covered?
- Quality: How does the plan rate on providing quality care?
1 AnswerMedicare now pays for an annual wellness visit and a personalized prevention plan. You will be able to work with your doctor to create a personalized prevention plan to keep you as healthy as possible. The wellness visit may include the following:
- An assessment of your health risks
- Your updated medical history
- A list of your current healthcare providers
- A list of your current prescription and over-the-counter medications
- Your height, weight, and blood pressure measurements
- A screening schedule for appropriate preventive services for you to follow over the next five to 10 years
- A list of your health risk factors along with treatment options
Those who are new to Medicare cannot get both the Welcome to Medicare exam and the annual wellness visit during their first 12 months of enrollment. The annual wellness visit takes place each year after that.