Finding out you need a transplant of any type can be overwhelming and worrisome. Not only does it come with the need for life-changing surgical procedures, but for many people, the cost is concerning. Does Medicare cover transplants? The answer is yes, for the most part.
One key thing that you need to know is that Medicare coverage is based on a person’s specific health needs. Transplants are considered, in most cases, the last resort to care. Organ transplants for livers, hearts, kidneys, lungs, and other organs are a life-saving procedure that comes with ample risk. Medicare pays for transplant care when it is the most necessary level of help for your needs, often after every other applicable treatment is exhausted.
How Does Medicare Cover Transplant Needs?
The type of Medicare coverage you have ultimately determines what Medicare will cover in terms of overall medical costs associated with a transplant. For most people with Original Medicare, the coverage will involve:
- Medicare Part A: This component of your Medicare coverage will cover hospital stay costs, which is typical of most transplants.
- Medicare Part B: This will cover your pre- and post-transplant doctor’s visits. It may also provide coverage for your screenings and diagnostics that are necessary to determine if you are a candidate for transplant, including both physical and mental health care.
If Medicare determines that an organ transplant is the necessary and likely best care option for you, it will cover costs related to the pre- and post-transplant care you will have. However, there are limitations to this policy that you need to know about, and that often means you should have supplemental coverage to extend your financial protections.
Medications with Transplant and Medicare Coverage
One of the most important reasons to have health insurance in place heading into your transplant is that you will likely need highly expensive, very important medications for the rest of your life to help prevent your body from rejecting the organ. These medications are not covered directly under Medicare Part A and B, though some may receive medication for a limited amount of time through the plan.
Most people will need to have Medicare Part D or prescription drug coverage in place. Part D prescription drug coverage is not a component of Original Medicare. Rather, it is a separate policy you need to have in place typically before your Medicare coverage kicks in to cover those very important medications.
When will Medicare pay for immunosuppressive drugs?
Immunosuppressive drugs, also called transplant drugs, are critical to sustaining life after a transplant. Medicare Part B covers this when Medicare pays for the transplant itself. That means that you must have Part A in place at the time of the transplant, and it must have covered the transplant costs. Part B will then cover the immunosuppressive drugs.
What Will Medicare Pay for in a Transplant?
Typically, Medicare Part A will provide for some of the costs you have during a hospital stay. This includes all of the necessary tests, lab work, and exams needed in the lead-up to the transplant. Then, it will likely cover the costs for:
- Heart transplant
- Lung transplant
- Kidney transplant
- Pancreas transplant
- Intestine transplant
- Liver transplant
In addition to this, Medicare also provides coverage for stem cell transplants when it is deemed the best type of care for your condition.
Medicare Part B will likely provide coverage related to the doctor-specific care you receive for your transplant. This includes your ongoing care and drug needs for immunosuppressant care.
Your Expected Transplant Costs with Medicare
Review your transplant costs with your social worker and insurance provider to make sure you know exactly what to expect. Typically, you will still need to pay for some costs, including:
- 20% of your Medicare-approved amount for all of the doctor’s services considered necessary leading up to and after your transplant once you meet the deductible for Part B.
- Various costs charged to you by the transplant facility and hospital
You do not have to pay anything to the living donor for a kidney transplant. You do not pay for any Medicare certified laboratory tests.
What About a Medicare Advantage Plan?
Medicare covers most of the costs associated with transplants because it is considered a life-saving treatment. However, if you need a kidney transplant, heart transplant, or other organ transplant and you have a Medicare Advantage Plan, you need to check with that provider to know what your specific coverage and limitations are.
The same applies to Medigap plans. This type of medical insurance will cover your costs as long as the transplant is considered necessary and life-saving. The covered transplant coverage amount will differ based on the Medigap plans themselves as well as the coverage limitations in place. You can check with your insurance company before you move forward to know what your Medicare supplement plan or advantage plan will and will not cover.
Other Factors to Know About a Medicare Covered Transplant
Consider the following details of coverage. Keep in mind that you should learn about this coverage in depth if you believe you may need to meet these needs.
Ensure you follow all rules required by Medicare
There are several things to keep in mind in this area:
- You must be eligible for care through a Medicare approved facility.
- Medicare covers organ transplants based on the plan’s coverage rules. When joining a Medicare Advantage plan, then, research coverage for the specific type of condition you have and the qualifications based on that plan.
- Choose healthcare providers that are approved by Medicare, not just a Medicare approved hospital.
- Know the rules for prior authorization. This could differ based on the plan you have. However, to ensure you get the transplant surgery covered, you must ensure you have met all of the coverage rules for prior authorization the plan puts in place.
- Organ transplant programs differ across the country. One facility may tell you that you need a double lung transplant, while another does not. The key here is that Medicare will likely need to approve the coverage based on medical tests and lab work itself.
End Stage Renal Disease and Medicare
If you have been diagnosed with end stage renal disease and need a kidney transplant. End stage renal disease ESRD, is a condition that may qualify you for Medicare immediately without the delay that is typical of Medical eligibility. Your Medicare coverage will include immunosuppressive drug coverage, which will continue for 36 months after a successful kidney transplant. You may need to seek immunosuppressive drug coverage beyond this.
What If You Are Not Eligible for Medicare?
Some people need organ transplants and are not Medicare beneficiaries, and it can take some time to qualify for coverage. As a result of that, you may need to explore other options for care in order to get on the transplant waiting list and receive coverage. If you do not qualify for Original Medicare or Medicare Advantage Plans, you may still be able to receive care through Medicaid services. Medicaid services may cover the out of pocket costs associated with the surgery. It also covers immunosuppressive drugs and doctor services you need.
If you are unsure if you will have coverage for the transplant surgery you need, work with the social worker to find out what additional options may be available to you.