Life After 50 Expo

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Dear Marci,

My mother is having a kidney transplant soon, and I am helping with the logistics of her recovery. I believe Medicare should cover the immunosuppressant drugs she will need after, but the details are confusing. How will her immunosuppressants get covered?

-Pauline (Austin, TX)

Dear Pauline,

As you likely know, after getting a kidney transplant, a kidney recipient will need to take immunosuppressant drugs for the rest of their life to prevent their body from rejecting the donor organ. Medicare covers these drugs differently depending on the circumstances:

Time-limited Part B coverage
If someone receives a kidney transplant in a Medicare-approved facility, Medicare Part B will cover their immunosuppressant drugs for 36 months after their hospital departure if:

They had Part A at the time of the transplant
They have Part B when getting their prescription filled
And, they are only eligible for ESRD Medicare
If the kidney transplant was successful, Medicare coverage will end 36 months after the month of the transplant

Note: If someone did not have Medicare at the time of their transplant, they can enroll retroactively in Part A within a year of their transplant.

Part B coverage for the rest of one’s life
If someone receives a kidney transplant in a Medicare-approved facility, Part B will cover their immunosuppressants for the rest of their life if:
They had Part A at the time of the transplant
They had Part B when getting their prescription filled
And, they qualify for Medicare based on age or disability

Part B-ID coverage
If someone’s ESRD Medicare benefits end 36 months after their transplant, they may qualify for Medicare’s new Part B-ID coverage of immunosuppressants if they:
Qualify for Part B coverage of immunosuppressants prior to losing ESRD Medicare
Do not have Medicaid or other public or private health insurance that covers immunosuppressants

Part B-ID coverage may not be the best choice if any other insurance is available. Part B-ID only covers immunosuppressant drugs and does not include coverage for any other Part B benefits or services. It also does not allow someone access to Part A.

Part D coverage
If someone does not have Part A when they receive a transplant, their immunosuppressants will be covered by Part D when they are enrolled in Medicare. Part D coverage for this type of drug typically means higher costs and additional restrictions, such as having to go to specific in-network pharmacies for drugs, as compared to coverage under Part B.

All Part D formularies must include immunosuppressant drugs. Step therapy is not allowed once someone is stabilized on their immunosuppressant drug. However, prior authorization can apply. This might mean a Part D plan will verify that, for example, Part B will not cover the drugs before providing coverage. It’s good to look for plans that have the fewest coverage restrictions and where one’s pharmacy is in-network and has preferred cost-sharing available to minimize costs and disruptions.

I hope this helps. I’m wishing your mom a successful transplant and speedy recovery!

-Marci

Dear Marci,

I missed my Initial Enrollment Period so am now planning to enroll this month during the General Enrollment Period. I’ve been hearing conflicting information about it from my family and friends, though. Has the General Enrollment Period changed?

-Rob (Indianapolis, IN)


Dear Rob,

Yes, there has been a major change to the General Enrollment Period (GEP), as of January 1, 2023. This may explain why you’ve heard some conflicting information about this enrollment period recently. Hopefully I can clear up any confusion for you!

First, the GEP takes place January 1 through March 31 each year. As you mentioned, the GEP is usually for people who missed their Initial Enrollment Period (IEP) and do not qualify for a Special Enrollment Period (SEP).

When you enroll during the GEP, there’s a good chance you’ll owe a premium penalty for not enrolling sooner. Because of this, using the GEP to enroll is not ideal.

Also, before 2023, if you enrolled during the GEP, your Medicare Part B would not start until July 1. This meant that even if you signed up with Social Security on January 1, your coverage would not be effective until July 1—six months later. That’s a long time to wait for health insurance!

Thanks to the passage of key parts of the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act in the Consolidated Appropriations Act of 2021, though, this months-long waiting period has been eliminated. As of January 1, 2023, enrollments made during the GEP are effective the first of the next month. This means that if you enroll in Medicare on January 20, for example, your coverage will be effective on February 1—not July 1 like in past years.

This is a big win for the Medicare program and its beneficiaries! It will also be great for you, Rob, when you use the GEP to enroll this year. Best of luck!

-Marci

Dear Marci,

I think my Part D premium is going up in 2023, which I expected. But I’ve also heard that everyone with Medicare might be saving money on drug costs because of recent legislation. How are drug costs changing in 2023?

-Jean-Claude (New York, NY)

Dear Jean-Claude,

It’s true that most people will experience some kind of change to their Part D costs each year. Part D plans can change the drugs they cover, their pharmacy networks, and their costs (such as premiums, copayments, coinsurance charges, and deductibles) from year to year. If you have Medicare prescription drug coverage, often referred to as Part D, your plan should have notified you about any changes in costs for 2023.

This year there are additional changes in Part D costs more generally due to the Inflation Reduction Act (IRA), which is likely the legislation you heard about. While some changes created by the IRA take effect in future years, the following changes take effect in 2023:

Insulin will be more affordable. The IRA limits co-payments to $35 per month for Part-D covered products and for insulin furnished under B, with no deductible for insulin products on your plan’s formulary. Currently, over 3 million Part D enrollees use insulin, and one in three people with Part D plans have diabetes. On average, in 2020, they paid $600 out-of-pocket for insulin. But some had considerably higher costs—25% spent over $800 and 10% spent over $1,300.

Because this change went into effect so quickly, the information about these lower costs was not always included in the Medicare Plan Finder tool during Fall Open Enrollment. This may have led some people to enroll in a plan that does not meet their needs. If you discover that you are not in the right plan, you may be able to change plans. Contact 1-800-MEDICARE (1-800-633-4227), your State Health Insurance Assistance Program (SHIP), or the Medicare Rights Center if you think this applies to you.

People with Medicare will be able to receive critical vaccines free of charge. The IRA eliminates cost-sharing and deductibles for Part D vaccines that are recommended by the Advisory Committee on Immunization Practices (ACIP), such as the shingles vaccine. This policy already applies to Medicare Part B and most private plans. Its expansion will save you costs and improve your access to necessary preventive care.

This will help the approximately 4 million Medicare beneficiaries who receive a Part D-covered vaccine each year—including the 3.6 million who received the shingles vaccine in 2020, at an average cost of over $100. However, it will also reach millions more. Research shows Part D immunization rates are well below those for Part B, likely due to cost-sharing. The additional expense is a well established barrier to beneficiary receipt of recommended vaccines.

You can read more about IRA changes that will take effect in future years here.

-Marci