Original Medicare and Medicare Advantage plans both cover certain types of approved stem cell therapy.
Medicare parts A and B, also known as original Medicare, provide coverage for approved stem cell treatments and the associated out-of-pocket costs. However, coverage varies between the different Medicare options.
The purpose of Food and Drug Administration (FDA)-approved stem cell therapy is to
This article discusses this type of stem cell therapy, examines the coverage and costs of each part of Medicare, and describes the specific procedures that Medicare covers. It also looks at the costs of inpatient stem cell therapy for people who do not have Medicare.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers part of the costs of two types of
Medicare Part A, which is hospitalization insurance, covers inpatient transplants. However, Part A pays only for admissions that fall under a regulation called the Two-Midnight rule. According to this rule, the admitting doctor expects a person to require a stay in a hospital for at least two midnights.
Although Part A is generally not appropriate for shorter hospital stays, Medicare may grant coverage on a case-by-case basis, depending on the admitting doctor’s judgment.
The cost associated with Part A is a $1,484 deductible. There is a $0 coinsurance for the first 60 days of a hospital stay.
Part B, which is medical insurance, covers outpatient transplants that healthcare professionals consider medically necessary.
The yearly deductible of $203 applies. Once a person meets the deductible, they usually pay 20% of the Medicare-approved amounts for doctor services and other costs involved in the therapy.
Medicare Advantage provides the coverage of parts A and B, while most plans also include prescription drug coverage.
Private insurance companies administer Medicare Advantage policies, and because of this, the out-of-pocket costs are different from those of original Medicare.
Out-of-pocket costs may also vary among plans, but all policies have a yearly cap on expenses. Additionally, an individual with Medicare Advantage must go to an in-network provider.
Medigap is Medicare supplement insurance. People who have original Medicare may buy a Medigap plan, which helps them pay out-of-pocket costs associated with parts A and B. The costs that this plan generally covers can include:
- deductibles
- copays
- coinsurance costs
Someone with original Medicare is eligible to enroll onto a Part D plan for prescription drug coverage that would include medications needed for stem cell therapy. Part D deductibles, copayments, and coinsurance costs vary according to the policy a person has purchased.
Medicare covers only two procedures: allogeneic hematopoietic stem cell transplantation (Allo-SCT) and autologous stem cell transplantation (Au-SCT).
Allo-SCT
In Allo-SCT, a healthcare professional will deliver healthy donor stem cells to a person through an IV infusion. The purpose is to restore normal blood production in someone whose body cannot perform this function.
A candidate for the transplant may be an individual with a deficiency in blood production, which can either be an inherited or acquired deficiency. An example could be a person with severe aplastic anemia.
Before the transplant, an individual will receive treatment to weaken the immune system — such as chemotherapy, radiation therapy, or both — so their body will not reject the donor cells. This treatment also allows the donor cells to reach the bone marrow, where they grow and make new blood cells.
With this procedure, there may be complications, which include rejection of the donor cells, despite the treatment to weaken immunity. Another possible complication is that the donor’s immune cells may attack a person’s healthy cells.
In addition to helping the beneficiary with costs, Medicare also assists the donor with costs. Covered donor expenses include doctor services, hospital care, and follow-up care.
Au-SCT
An Au-SCT procedure restores stem cells without the help of a donor. The transplant aims to enable the body to resume blood production and development after the organs and tissues sustain damage.
Candidates for the transplant include those with blood cancers, such as lymphoma or leukemia.
Before an Au-SCT transplant, a health professional
If the procedure is successful, the transplanted cells make new blood cells within the bone marrow.
Au-SCT has a higher relapse rate than Allo-SCT, but Au-SCT does not carry the risk of a healthy cell attack because it does not involve donor cells.
Stem cell therapy can be very expensive. A 2017 study examined the costs of 1,562 people who had inpatient Allo-SCT or Au-SCT between 2010 and 2013. The researchers discovered that the costs for these treatments ranged between
However, the costs in the study were from claims individuals made to private health companies rather than to Medicare. The research also did not provide an estimation of the outpatient costs of stem cell therapy.
People with Medicare are eligible for coverage of two types of stem cell transplants. Candidates for these therapies may include individuals with a blood disorder, such as aplastic anemia, or someone with blood cancer, such as lymphoma.
If a person has original Medicare, they can enroll onto a Medigap plan, which helps with out-of-pocket expenses. An individual with a Medicare Advantage plan will have out-of-pocket costs that differ from those of original Medicare.
Note that stem cell therapy is costly. Before undergoing one of the transplants, a person may wish to check their Medicare plan to get an estimate of both covered and out-of-pocket costs.