top of page
Search

CMS proposes extended medicine coverage for transplant recipients in a proposed rule

Writer's picture: Jay BlumJay Blum



CMS has issued a proposed rule establishing eligibility standards for a new statute that will provide immunosuppressive medicine coverage to more kidney transplant recipients.


In December 2020, Congress approved the extended coverage. In January, the rule would go into force. 


If a patient has end-stage kidney disease and is over 65 years old, Medicare automatically covers lifetime immunosuppressive medicine coverage if they have had a kidney transplant. When a person under the age of 65 obtains a kidney transplant, their Medicare coverage stops three years later unless they are qualified for Medicare for another reason, such as age or disability.


Advocates for extending drug coverage claim that the 3-year restriction on Medicare benefits has caused patients who have been unable to get insurance to reduce their doses due to the high expense of the drugs, resulting in transplant rejection and a return to dialysis.


The National Kidney Foundation said in a statement after the U.S. House passed the measure in 2020, "With transplant patients suffering disproportionately from the deleterious consequences of COVID-19, this legislation is more necessary today than ever." "Patients must be assured that they will have access to their life-saving immunosuppressive medications and will not have to worry about missing doses due to financial constraints."


Other than immunosuppressive medicine coverage, individuals less than 65 years old who undergo a transplant are not eligible for Medicare coverage for any services or drug prescriptions.


The cost of insurance

According to a research provided by HHS in 2019, extending immunosuppressive drug coverage will cost Medicare more money, but it would save money by reducing the number of patients returning to dialysis due to graft failure. According to the report, "... the federal investment required to cover the costs of extending coverage for immunosuppressive drugs would grow at a slower rate than the savings generated by avoiding cases of reversion to dialysis, resulting in net savings of $0.1 million in the fifth year of policy implementation and increasing in each subsequent year, resulting in an accumulated 10-year savings of approximately $73.4 million." "If current trends continue, the annual savings to Medicare, as well as the total net savings, will climb each year."


After the program began in January, CMS predicted an annual increase of 250 registrants.  "Healthcare is more than just mending broken bones and giving medications. In a news statement announcing the proposed regulation, HHS Secretary Xavier Becerra said, "It's about giving folks the peace of mind that comes with having coverage when you need it." "That's why we're proposing this rule today to help people with Medicare avoid delays, close gaps, and gain access to care."


Enrollment

According to Becerra, the new law allows HHS to use special enrollment periods for Medicare beneficiaries with exceptional conditions, such as a transplant, so that patients who want expanded coverage can enroll immediately after the transplant rather than waiting for the next open enrollment period for Medicare benefits.


"CMS is committed to ensuring that people who are eligible for Medicare receive it in a timely manner. If implemented, this proposed rule will shorten the time it takes for people to get Medicare coverage after enrolling, furthering CMS' strategic aim of extending access to excellent, affordable health coverage and care, according to CMS Administrator Chiquita Brooks-LaSure. "CMS is appreciative to Congress for allowing us to establish special enrollment periods for Medicare, which will help persons with extraordinary needs avoid coverage gaps and late enrollment penalties."


According to the statement, qualified persons can enroll in the new immunosuppressive drug benefit beginning in October 2022, with coverage commencing as early as January 1, 2023, if the proposed policy is implemented.


Comments on the proposed rule must be filed by 5 p.m. on June 27 and can be found at www.cms.gov/files/document/cms-4199-p.pdf. Electronic comments can be addressed to www.regulations.gov.


References:

Implementing provisions of the Consolidated Appropriations Act of 2021, as well as additional changes to Medicare enrollment and eligibility rules (CMS-4199-P) www.cms.gov/newsroom/fact-sheets/implementing-certain-provisions-consolidated-appropriations-act-2021-and-other-revisions-medicare-1 The date is April 22, 2022. The date was May 5, 2022.


www.healio.com/news/nephrology/20201210/us-house-of-representatives-approves-bill-offering-lifetime-transplant-drug-coverage

12 views0 comments

Recent Posts

See All

Comments


P: 216-236-3225    |   F: 440-739-7446   |   E: info@blumfamfdn.org

© 2011 - 2023 Blum Family Foundation, Inc. All Rights Reserved

bottom of page