Kidney Transplants: Medicare Coverage of Immunosuppressive Drugs

What GAO Found

Medicare offers a benefit that helps certain kidney transplant patients pay for immunosuppressive drugs they need to prevent their bodies from rejecting their new kidney. Patients are eligible for this immunosuppressive drug benefit if they had Medicare coverage for their kidney transplant, that coverage has ended, and they are not enrolled in certain types of health coverage.

The benefit, which took effect on January 1, 2023, is limited to immunosuppressive drugs, and does not cover other Medicare services. When patients enroll in the benefit, they attest to having no other coverage for immunosuppressive drugs. They pay monthly premiums and cost sharing, including 20 percent of the Medicare-approved amount for the drugs.

There were 104 patients enrolled in the benefit as of February 2024. In addition, another 146 patients enrolled and then disenrolled in the benefit from January 2023 through February 2024 due to various reasons, such as nonpayment of premiums.

Officials from the Centers for Medicare & Medicaid Services (CMS) told GAO that CMS reviews enrollment data it receives from the Social Security Administration to check patient eligibility for the benefit. For example, for each enrollment record, CMS checks for prior Medicare coverage, kidney transplant date, and effective date of benefit enrollment. If any enrollment records appear invalid, CMS notifies the Social Security Administration for clarification and corrective action. CMS officials also told GAO that they send an annual letter to enrolled patients reminding them of the benefit's eligibility requirements. CMS's efforts at the time of GAO's review are consistent with agency statements that CMS will monitor compliance with the benefit's eligibility requirements and address any concerns.

Why GAO Did This Study

The Consolidated Appropriations Act, 2021 included a provision for GAO to review the implementation of the immunosuppressive drug benefit. This report provides information on Medicare's immunosuppressive drug benefit, including enrollment and oversight activities taken by CMS.

To conduct this work, GAO reviewed relevant federal statutes, regulations, documentation, and guidance and interviewed CMS officials about the benefit and steps to monitor compliance. In addition, GAO analyzed enrollment data provided by CMS for January 2023 (when the benefit was implemented) through February 2024 (the most recent available data). GAO also interviewed five stakeholder groups representing kidney transplant patients, providers, and those assisting patients with their coverage options to obtain their views on the benefit.

For more information, contact Leslie V. Gordon at (202) 512-7114 or [email protected].

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