HR1458 and S565

I hope you don’t mind a bit about transplants, but I noticed S565 and HR1458, the federal bills to extend Medicare payment for transplant drugs, are still languishing in committee in Washington. I thought it would be a good idea to gather a list of representatives with their contact info and post it on the web, so I did:

Senate bill S565

House bill HR1458

I’ve written most of the reps and already have a couple of responses I posted.

Starting in 2011, due to the bill the President signed yesterday, people with preexisting conditions will have access to state run high risk pools (like already exists in WA state). In 2014 people who earn up to 133% of the federal poverty level will qualify for Medicaid (even those without dependent children - a first in 43 states), from 133% to 400% people can but insurance with a subsidy in the exchange, above 400% you pay the entire premium but you are guaranteed access without consideration of a preexisting condition.

The exchanges and the state high risk pool has to offer pretty decent policies - ones that almost certainly include immunosuppressant drugs. I say almost because I have yet to find the definitive link but I’m not aware of insurance that currently does not cover immunosuppressants.

What is not going to be covered that requires the Medicare extension?

How much will these high-risk pools COST to consumers, though? Any sense of that?

The cost of the insurance is what insurance would cost if you didn’t have whatever condition it is that you have -for someone with a transplant I think the coverage would include immunosuppressant drugs, for someone on dialysis if you were in the first 33 months (edit 3/28:thanks for flagging the lapse Beth) then the high risk insurance would be primary. The bill directs 5 billion to the job. During the campaign McCain’s proposal included high risk pools. At the time the campaign said that would cost about 7 to 10 billion - and McCain’s version had high risk pools playing a bigger role which is analogous to the current situation since the increased access to Medicaid won’t happen until 2014 when everyone is going to move to the exchange or Medicaid.

There is some doubt about if the MSP rules would apply, a concern that I have heard that somehow MSP wouldn’t apply to the exchange insurance or the high risk pool. That doesn’t make sense though so I’d need to hear that officially to spend time trying to understand it.

I have a question - if you have Medicare due to age and use immunosuppressant drugs due to a kidney transplant, are the immunosuppressant drugs covered through Part B or Part D?


I assume you meant in the first 33 months (not days) of Medicare eligibility in your post. Actually for patients who choose to start a home dialysis program prior to the first day of the third FULL month of dialysis, Medicare could start Day 1 of the month regular dialysis started. Medicare would be primary unless someone has coverage through an employer. If the person has employer group coverage, Medicare would be the secondary payer starting Day 1 of month regular dialysis started.

Medicare coverage for immunos lasts as long as you have Medicare (specifically Medicare Part B – the part of Medicare that covers immunos). If you have Medicare due to ESRD ONLY, Medicare lasts 36 months post-transplant but if you become eligible for Medicare due to age or disability later, assuming you meet the following criteria your immuno coverage resumes. To have Part B coverage of immunos:

  1. You had to have your transplant in a Medicare approved transplant program;
  2. You had to have Medicare Part A coverage at the time you got the transplant (it’s OK if your employer insurance paid 100% of the cost); and
  3. You had to have Medicare Part B when you wanted Medicare to pay for your immunos.

Medicare Part D is not supposed to cover drugs that could have been covered under Part A or B if you were eligible for Medicare and chose not to take it. Therefore, as I see it, Medicare Part D is not supposed to cover immunos for a transplant for someone unless he/she wasn’t eligible for Medicare Part A at the time he/she got the transplant or he/she got the transplant somewhere that wasn’t Medicare approved.

Thanks Beth, I did mean months.

This suggests that immunosuppressant drugs would be covered by a basic policy in the exchange or the high risk pools. And under an expanded Medicaid.

Not sure where the extension fits in other than as a bridge until 2014. If a bridge would be helpful than that legislative language needs to be written sooner rather than later. There are a number of lobbying needs compelled by this legislation given the many decisions that were left up to DHHS … here’s where a letter from a Congressional office could do some real good.