KIDNEY STORIES: HAS THE ACA EXPANDED MEDICARE’S IMMUNOSUPPRESSIVE DRUG COVERAGE FOR KIDNEY TRANSPLANT RECIPIENTS?

HAS THE ACA EXPANDED MEDICARE’S IMMUNOSUPPRESSIVE DRUG COVERAGE FOR KIDNEY TRANSPLANT RECIPIENTS?

          I had a conversation with my doctor last week. (My nephrologist, Dr. Vavilala, we call him Dr. V).  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.[i]  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.[ii] Here is where the gap in coverage comes in; if you’re 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.[iii] Coverage for anti-rejection drugs for those patients that fall into the gap is limited to 36 months.[iv] 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,[v] 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.[vi]

          So what happens to the transplant patient who has to make the choice between heating, eating & driving or taking his immunosuppressive medications?  An all too common scenario for those that fall into the gap is they skip their meds, their newly implanted kidneys fail, and they end up back on dialysis.[vii]

          This is particularly maddening when you consider that your life expectancy on dialysis is about 5 years and your life expectancy from a live transplant can be 12-20 years, with a much better quality of life.[viii] This is particularly striking when you consider that some transplants have lasted as long as 40 years.[ix]

          Another big factor to consider is costs.  The National Kidney Foundation makes the following comparison between the cost of a transplant and the costs of dialysis,

“Medicare spends an average of $86,316 per year for an individual who is on dialysis and $124,643 during the first year of a kidney transplant.  However, after the year of transplant, the cost is much lower at $24,612 for an individual with a functioning kidney transplant.  If the transplant fails, the patient returns to dialysis or receives another transplant, each covered again by Medicare.[x]

          Think about that for a minute; almost a $60,000/year savings by simply preserving and protecting a transplanted kidney! The NKF has proposed legislation for years to plug this gap, but despite wide-spread acceptance, the bill has yet to become law.[xi]

          To answer the doctor’s question, we look to the NKF blog on the subject:  

“We are confident that the declining cost of the drugs, coupled with the fact that many currently uninsured transplant recipients will be able to purchase insurance under the Affordable Care Act (ACA), will make H.R. 1428 / S. 323 very cost effective and increases the possibility of congressional approval.  The CRS study reviewed preliminary information on the ACA’s essential health benefits (EHB) benchmark plan in multiple states, and found that the plans will typically require health plans to cover these immuno drugs.  Thus, since more people will have insurance coverage, fewer will need the extended Medicare benefit, lowering the cost of H.R. 1428 / S. 323.”(emphasis added).  [xii]

          In other words, in the opinion of the National Kidney Foundation, the ACA may now cover that gap in coverage for the immunosuppressant drugs, extending the 36 months in coverage to coverage for a lifetime.  The NKF has made clear that they are still pursuing a bill to extend this coverage and preventing insurance carriers from cancelling you once you have coverage.[xiii]

          I then located the study referred to in the NKF blog.[xiv] The article notes that in 2007, the Government Accountability Office (GOA) found the percentage of kidney transplant failures had nearly doubled when examining the results after a 7 year period, post-transplant.[xv]  The study attributed at least part of this failure to patients not taking anti-rejection meds due to prohibitive costs after the 36 month period had run.[xvi] The article notes that beginning in 2014, patients with a kidney transplant who are no longer entitled to Medicare payments for their anti-rejection meds may have access to extended coverage under the ACA.[xvii] The CRS paper went on to note that a random sampling of plans covered prescription drugs, presumably including immunosuppression drugs used by ESRD patients to prevent transplanted kidney rejection.[xviii] More to the point, the ACA beginning in 2014 requires private health plans offered through exchanges to cover essential health benefits (EHB).[xix] The 2012 benchmark standards require all plans available in exchanges to cover drugs in the immunosuppressive class.[xx] What this means in plain English is that somewhere between 3-24 anti-rejection drugs and roughly 20 products must be covered by state exchanges including common immunosuppressive drugs used by kidney transplant recipients.[xxi] This comes as potentially good news for kidney transplant patients!

 


[i] Flyer from the National Kidney Foundation entitled “Immunosuppressive Drug Coverage” distributed on March 13, 2013.  See Also: www.kidney.org/…/ImmunosuppressiveDrugCoverage113thCongress.pdf (Accessed 2013).

 

[ii] Id. 

[iii] http://ssa-custhelp.ssa.gov/app/answers/detail/a_id/168 (Accessed 2013)(Age limit is 65); http://www.cpmc.org/advanced/kidney/patients/topics/kidney_eval_disability.html (Accessed 2013)(“ Social Security benefits continue for 12 months following transplant surgery. At that point, Social Security re-evaluates each case, but unless you have another disabling condition (blindness, stroke or severe amputation) or are over 65, your Social Security benefits end.”); www.medicare.gov/Pubs/pdf/11360.pdf‎; (Medicare coverage ends 12 months after you stop dialysis); http://www.dallasnews.com/investigations/problem-solver/20121122-kidney-transplant-recipient-approaching-anti-rejection-drug-deadline.ece (2012)(“ Medicare covers kidney patients under the age of 65 for only 36 months after the transplant surgery, a limit written into the statute under the Social Security Act. The rationale for the ruling is that younger patients will recover from end-stage renal disease following the transplant, get a job and buy private insurance through their employer. But Dawson — like many other transplant recipients — is unlikely to be hired.”)

[iv] Flyer from the National Kidney Foundation entitled “Immunosuppressive Drug Coverage” distributed on March 13, 2013.  See Also: www.kidney.org/…/ImmunosuppressiveDrugCoverage113thCongress.pdf (Accessed 2013).

 

[vi] Flyer from the National Kidney Foundation entitled “Immunosuppressive Drug Coverage” distributed on March 13, 2013.  See Also: www.kidney.org/…/ImmunosuppressiveDrugCoverage113thCongress.pdf (Accessed 2013).

 

[vii] Id.  (“Transplant recipients often have difficulty finding other coverage for their immunosuppressive drugs after Medicare coverage ends… Extending immunosuppressive coverage beyond the 36-month post-transplant limit would improve outcomes and enable more kidney patients who lack adequate insurance to consider transplantation.  Most transplant recipients also have a higher quality of life, and are more likely to return to work than dialysis patients.”).

 

[viii] http://www.kidneyfund.org/kidney-health/kidney-basics/common-questions.html#How_long_can_a_person_live_on_dialysis (Accessed in 2013)(“… the average life expectancy for all dialysis patients is currently between five and six years.”); http://www.bidmc.org/Centers-and-Departments/Departments/Transplant-Institute/Kidney/The-Benefits-of-Transplant-versus-Dialysis.aspx (Accessed in 2013)(“ A living donor kidney functions, on average, 12 to 20 years, and a deceased donor kidney from 8 to 12 years. Patients who get a kidney transplant before dialysis live an average of 10 to 15 years longer than if they stayed on dialysis. Younger adults benefit the most from a kidney transplant, but even adults as old as 75 gain an average of four more years after a transplant than if they had stayed on dialysis. – See more at: http://www.bidmc.org/Centers-and-Departments/Departments/Transplant-Institute/Kidney/The-Benefits-of-Transplant-versus-Dialysis.aspx#sthash.HSuqLkEr.dpuf”).

[x] Flyer from the National Kidney Foundation entitled “Immunosuppressive Drug Coverage” distributed on March 13, 2013.  See Also: www.kidney.org/…/ImmunosuppressiveDrugCoverage113thCongress.pdf (Accessed 2013).

 

[xi] https://nkfadvocacy.wordpress.com/immunosuppressive-drug-coverage/ (2013)(“ Sens. Richard Durbin (D-IL) and Thad Cochran (R-MS) introduced S. 323 on February 13, 2013, to extend Medicare coverage of immunosuppressive drugs for kidney transplant recipients.  Medicare covers dialysis for most Americans, regardless of their age, with no time limit. However, if they are under age 65 or are not Medicare-disabled (receiving Social Security Disability Income), their eligibility ends 36 months after receiving a transplant.  S. 323 eliminates the 36 month time limit to provide continued Medicare coverage for life-saving immunosuppressive medications. All other Medicare would end after three years for kidney recipients, as under current law.

Please contact your Senators and urge them to cosponsor S. 323 to help transplant recipients access the medications they need to maintain their new kidney.

Senate Co-sponsors:

Rep. Michael Burgess (TX) and Rep. Ron Kind (WI) introduced H.R. 1428 to amend title XVIII of the Social Security Act to provide Medicare entitlement to immunosuppressive drugs for kidney transplant recipients. This bill would extend Medicare’s coverage of anti-rejection drugs for kidney transplant recipients (who are not Medicare-aged or Medicare-disabled) for the life of the transplant, versus the 36 months post-transplant that Medicare currently covers.

Please contact your Representative and urge them to cosponsor H.R.1428 to help transplant recipients access the medications they need to maintain their new kidney.

House co-sponsors:

[xiv] Talaga, Medicare Immunosuppressive Drug Coverage for Kidney Transplant Recipients (2013).

 

[xv] Id.,  United States Government Accountability Office, End-Stage Renal Disease: Characteristics of Kidney Transplant Recipients, Frequency of Transplant Failures, and Cost to Medicare, September 2007, p.16, http://www.goa.gov/assets/270/267345.pdf.

 

[xvi] Id.

 

[xvii] Talaga, Medicare Immunosuppressive Drug Coverage for Kidney Transplant Recipients, July 16, 2013, p. 5, www.law.umaryland.edu/…/crsreports/crsdocuments/R43154_07162013.

[xviii] Id.

 

[xix] Id.

 

[xx] Id.  See Also:  CRS Report R42663, Health Insurance Exchanges under the Patient Protection and Affordable Care Act(ACA), by Benadette Fernandez and Annie L. Mach.

[xxi] http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb-rx-crosswalk.pdf; Talaga, Medicare Immunosuppressive Drug Coverage for Kidney Transplant Recipients, July 16, 2013, p. 6, www.law.umaryland.edu/…/crsreports/crsdocuments/R43154_07162013.

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