Receiving a transplant can be an overwhelming experience. The life-changing procedures aside, the expense associated can potentially cripple many people financially. If you are a senior facing this medical situation, one of your questions will likely be “Does Medicare cover transplants?”
Luckily, the answer to that question is yes, the program does cover most parts of a medical transplant.
Yet it is also important to know that the coverage provided by Medicare is based on your specific health needs. And since organ transplants for livers, hearts, kidneys, and other organs are important procedures that come with significant risk, Medicare will only pay for them and the care afterward when they are the last resort — after all other applicable treatments have been considered or tried.
Transplant Needs Coverage Under Medicare
As in many other medical needs, the coverage provided by Medicare for the cost associated with transplant surgeries depends on the type of Medicare you have. If you have Original Medicare, the likely coverage will be the following:
Medicare Part A: This part of Medicare will cover the cost of hospitalization, which is typically needed for most transplants.
Medicare Part B: Coverage includes your pre- and post-transplant doctor’s visits, as well as your screenings and diagnostics that are necessary to determine if you are suitable for transplant. It covers both physical and mental health care.
Once Medicare finds that an organ transplant is the best care option for you and approves the procedure, the related cost to the pre- and post-transplant care will be covered. Yet like other medical care, Medicare coverage for transplants has its limits, which means that you will need to seek supplemental coverage if you wish to expand or extend your protections.
Medicare Coverage for Transplant-Related Medications
Many people who have gone through transplants require medications for life to help keep their bodies from rejecting the organs. As these medications are often expensive and not covered directly by Medicare Part A and B, it is important to ensure that you have health insurance plans in place that cover them if you are heading into a transplant.
One option is to get Medicare Part D, or the prescription drug coverage component of Medicare that is not a part of Original Medicare. It is a different and separate policy that can cover those very important medications for those who have undergone transplants.
Does Medicare Pay for Immunosuppressive Drugs?
Immunosuppressive drugs, also known as transplant drugs, are one of the drugs that may be needed to help a patient sustain life after a transplant. The good news is that sometimes Medicare pays for them — if you already have Medicare Part A at the time of your transplant and it covers the cost of the procedure, then Part B will likely cover these drugs.
What Does Medicare Cover for Your Transplant?
Medicare Part A: Part A typically pays for part of the costs of your hospital stay, including all the necessary tests, exams, and lab work leading up to the procedure. It will also pay for the following:
Heart transplant
Lung transplant
Kidney transplant
Pancreas transplant
Intestine transplant
Liver transplant
Medicare Part A also covers stem cell transplants if it is determined to be the best care option for your condition.
Medicare Part B: Part B normally provides coverage on doctor-specific care for your transplants, including your ongoing care and, as mentioned earlier, your immunosuppressant drugs.
What are Your Expected Costs For Transplant with Medicare
The people who can give you an accurate estimate of the cost related to a transplant is your health care or insurance provider, so make sure you check with them. Normally, even with Medicare coverage, you will need to pay for the following:
20% of your Medicare-approved amount for all necessary doctor services 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
Items won’t have to pay for include fees to living donors for a kidney transplant, as well as any Medicare-certified lab tests.
What Transplant-Related Cost Does a Medicare Advantage Plan
If you already have a Medicare Advantage Plan (Medicare Part C) and want to find out what specific coverage and limitations it provides in relation to kidney transplants, heart transplants, or other organ transplants, you should check with your insurance providers.
The same goes for Medigap plans. Like Original Medicare, this type of medical insurance plan will cover transplants that are considered necessary and life-saving. The coverage amount and limitations will vary based on the Medigap plans you have. Again, it is important to check with your insurance providers about what the plans will and won’t cover before moving forward with the transplant.
What Else Do I Need to Know About Medicare-Covered Transplants?
The following rules, which are required by Medicare, are worth keeping in mind when you are considering moving forward with a transplant.
Medicare Rules:
You must be eligible for care through a Medicare-approved facility.
Medicare covers organ transplants based on the plan’s coverage rules. When choosing a Medicare Advantage plan, make sure you research the coverage for your specific condition and the qualifications based on that plan.
Both the healthcare providers and hospitals you choose should be approved by Medicare.
Make sure you understand the rules for prior authorization as it could vary by the plans you have. You must meet all of these coverage rules to ensure that you get the transplant surgery covered.
Organ transplant programs differ across the country. Different facilities may tell you that you need different things, but at the end of the day, Medicare will likely make the decisions on your coverage based on medical tests and lab work itself.
Medicare Coverage for End Stage Renal Disease
End stage renal disease (ESRD) is a condition that may require a kidney transplant. If you are suffering from this, Medicare may qualify you for treatment immediately without the delay that is typical of Medical eligibility. Your coverage will likely include continuous immunosuppressive drug coverage for 36 months after a successful kidney transplant, though you need to find other plans that can provide coverage for the drug beyond this.
What are the Options if I am Not Eligible for Medicare?
For those who are not Medicare beneficiaries but are in need of organ transplants, other options may need to be explored. One way is to check the eligibility for Medicaid services, which may cover the out-of-pocket costs associated with the surgery and possibly the immunosuppressive drugs and doctor services required.
Alternatively, if you are on Original Medicare but want to know more about the extra protection offered by Medicare Advantage Plans or Medigap when it comes to transplants, consider speaking to a licensed agent or broker.
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