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Questions and Answers on Immunosuppressive Drugs Coverage Legislation

Q. When is a transplant patient eligible for Medicare?

A. In the case of end stage renal disease (ESRD), which is irreversible kidney failure, Medicare covers individuals under age 65 if they are on dialysis or if they receive a kidney transplant. For other organs, an individual is eligible by reason of age or disability.

Q. Which transplant recipients are eligible for Medicare payment of immunosuppressive medications under current law?

A. Anybody who has received a Medicare-eligible transplant (regardless of whether Medicare paid for the transplant and even if the individual's private health insurance paid for it) is entitled to Medicare coverage, under Medicare Part B, for their immunosuppressive medications for 36 months post-transplant.

Q. Do all transplant recipients require these medications?

A. Yes. Transplant recipients must take these medications daily for the life of their transplant. Otherwise, they significantly increase the chances of organ rejection.

Q. Shouldn't these individuals pay for the medications themselves?

A. Many transplant recipients are fortunate enough to have health coverage to pay for these drugs, perhaps because they have returned to employment or perhaps because they have coverage through their spouse. Others are not so fortunate. Private insurance is difficult to obtain and is very expensive.

These drugs are very costly. The average annual cost for immunosuppressive medications for kidney transplant recipients is approximately $11,000. Many transplant recipients also have additional medical conditions such as diabetes and hypertension and they often must pay for medications for these needs as well, increasing their total out-of-pocket expenses.

Q. Why should Medicare pay for the drugs?

A. Medicare has an investment in the transplant. Maintaining the transplant is less expensive than the cost of re-transplantation, which might be required if the transplant failed because of financial reasons. Kidney transplant recipients might need or want to return to dialysis instead of getting a second transplant, and Medicare pays for dialysis and related services for dialysis patients at an average annual cost $49,000.

Q. How do transplant recipients obtain their medications if they do not have private insurance?

A. A few transplant recipients are fortunate enough to be able to afford their medications. Others may be eligible for Medicaid or for other state financial assistance programs, such as State Kidney Programs, but eligibility for these programs varies from state to state and from time to time. Thousands of individuals earn too much to qualify for these assistance programs yet cannot afford costly medications. Many others are forced into dire financial straits by reaching their maximum limit on credit cards, missing mortgage payments, etc. Many also risk organ rejection by rationing their medications. Some transplant patients may be eligible for assistance through pharmaceutical companies.

Q. How would H.R. 1115 change current coverage?

A. H.R. 1115 would eliminate the 36-month time limitation for immunosuppressive drugs and extend it indefinitely for transplant recipients who have received a Medicare-covered transplant and are eligible for Medicare 36 months post-transplant by virtue of age or disability.

Q. How many people would be affected by the House bill?

A. It is estimated that about 25,000 people who have received a Medicare-covered transplant and are currently entitled to Medicare benefits would be affected by H.R. 1115.

Q. How much would the bill cost?

A. H.R. 1115 has not received a cost estimate from the Congressional Budget Office, but identical legislation in the 104th Congress was "scored" to cost $233 million over six years and save Medicaid $29 million over six years.

Q. How would S. 631 change current coverage?

A. S. 631 would eliminate the current 36-month time limitation for coverage and extend Medicare coverage of immunosuppressive drugs indefinitely to all individuals who have received or will receive a Medicare-eligible transplant, regardless of their Medicare eligibility status post-transplant. Additionally, it would make Medicare the secondary payer indefinitely for immunosuppressive medications.

Q. What does "secondary payer" mean and how does it impact Medicare coverage?

A. When an individual has two sources of medical insurance (often by having their own insurance and their spouse's insurance or by having Medicare coverage and an employer-provided insurance), one is usually the primary payer and one is the secondary payer. The primary payer is the first to pay for a medical expense and the secondary payer picks up whatever the primary payer doesn't cover.

Q. How many people would be affected by the Senate bill?

A. The Senate bill would immediately affect about 75,000 people who have already received a transplant covered by Medicare. It would also cover anyone who receives a Medicare-covered organ in the future and does not have any insurance coverage for their immunosuppressive medications after 36-months post-transplant.

Q. What is the cost estimate for S. 631?

A. The Congressional Budget Office has not yet scored the Senate bill. Preliminary indications from the CBO in 1998 were that the bill would cost approximately $700 million over five years.

Q. Is there a difference between S. 631 and H.R. 1115?

A. Yes. The House bill would provide indefinite immunosuppressive coverage only to those individuals with Medicare-covered transplants who remain eligible for Medicare benefits due to age or disability 36 months post-transplant. The Senate bill contains the same provision as the House bill. It would also create a new entitlement for transplant medications only for those beneficiaries who lose their Medicare eligibility 36 months post-transplant.

Q. Why should Congress enact legislation specific to transplant patients at a time when Medicare prescription drug benefits are being considered?

A. Many of the Medicare prescription drug proposals include annual caps as low as $1,000 - $2,000, which represent only a small fraction of the cost of immunosuppressives. Many transplant recipients would still be faced with tremendous personal outlays for their medications even if Congress enacted a new prescription drug benefit for all Medicare beneficiaries. Furthermore, kidney transplant recipients lose entitlement to Medicare benefits 36 months after transplantation, unless they are over age 65 or disabled.

This information was provided by the Immunosuppressive Drugs Coalition, of which TRIO is a member.

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