Sorting Out Who Pays (Medicare or Medicaid) For Anti-Rejection Meds for a Transplant Recipient
Navigating health insurance can be confusing for people who are dual eligible. Note: Dual eligibility refers to older adults and people with disabilities who have limited income and resources and qualify for both Medicare and Medicaid coverage. Janet, a 47-year-old living in Washington County, knows this frustration all too well. Janet had a kidney transplant almost 30 years ago and still takes multiple anti-rejection medications. She only receives $900/month from Social Security Disability and her medication was costing almost $100. Concerned, Janet reached out to PHLP.
PHLP realized that her medication shouldn’t cost anywhere near this amount and quickly set to work to get this problem resolved for Janet so she could get this important medication. Janet had a Medicare Advantage plan for dual eligibles. Because Janet had Medicare at the time of her kidney transplant, the anti-rejection medications are covered under Medicare Part B instead of Medicare Part D. Her Medicare Advantage plan should have paid for it under the Part B medical benefit as required for her situation. PHLP contacted Janet’s pharmacy to see if they had billed her Medicaid coverage for the Part B coinsurance amount. The pharmacist said they did but it was not going through, and he was not clear why.
PHLP then reached out to staff in the pharmacy department at the Pennsylvania Department of Human Services to find out why the ACCESS card was not covering the remaining cost of the anti-rejection medication. DHS staff said the pharmacy needed to call their hotline and confirm that Janet’s insurance covered the medication under Medicare Part B (not Medicare Part D) and then staff could enter an override for the ACCESS card to cover the medication. PHLP relayed this information to the pharmacy and they made the needed call. Janet was then able to get her anti-rejection medication for a small Medicaid co-pay ($1.00)! She was thrilled and relieved that she would be able to get these vital medications at a price she could afford!