Medicare covers essential transplant services for those who meet the eligibility criteria.
Almost 40,000 organ transplants took place in the United States in 2019, according to the United Network for Organ Sharing (UNOS). This number is 8.7% higher than in 2018. UNOS also state that the number of organ transplants has hit record highs for the last 7 consecutive years.
As transplants are becoming more common, a person may wish to know whether Medicare covers these vital procedures, should they be necessary.
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 transplants and other medically necessary health services to ease a person’s financial responsibilities.
A doctor must declare that an individual needs a transplant for them to be eligible for coverage. Medicare then covers the costs for both the person receiving a transplant and the person donating their organ, if they are alive.
Which Medicare parts cover transplants?
Original Medicare parts A and B both cover a portion of the costs of transplants.
For a person receiving a transplant and the living person donating an organ, Medicare Part A covers:
- blood transfusions and processing
- essential lab tests and examinations
- follow-up care
- hospital services associated with organ transplants
- immunosuppressive medications that doctors provide in the hospital
- kidney registration fee, if applicable
- organ sourcing and procurement
- stem cell transplants
Medicare Part B covers further transplant-related costs, including:
- corneal transplants
- doctor’s services associated with organ transplants
- immunosuppressive medications if they are necessary for a Medicare-covered transplant
People with a Medicare Advantage (Part C) plan have the same coverage level as those with original Medicare.
Medicare covers a wide variety of transplants, including:
- stem cell
The person receiving an organ and the living person who is donating theirs both need appropriate aftercare when recovering from the transplant procedures.
Medicare covers the costs associated with these treatments, including:
- home healthcare
- hospice care
- nursing home care
Doctors recommend transplants for two reasons: saving a person’s life or improving its quality. They recommend a transplant if someone’s organs are not working efficiently or at all.
A doctor may consider a transplant when they have exhausted all other treatment options, and a transplant is the only lifesaving option available.
People with certain diseases may qualify for transplants, including those with:
- bone marrow disease
- chronic obstructive pulmonary disease (COPD)
- cystic fibrosis
- multiple myeloma
- severe bronchiectasis
- sickle cell disease
Doctors might also suggest a transplant if they feel that it will improve a person’s quality of life.
For example, they might recommend a corneal transplant if someone sustains an eye injury that leads to blindness. Being blind is not life threatening, but a corneal transplant could restore sight and improve an individual’s quality of life.
Most people undergoing transplants still face some Medicare costs for their treatment, except for living donors, whose costs Medicare covers in full.
Medicare-approved laboratory tests are also cost-free, but a person can usually expect to pay:
- 20% of the Medicare-approved amount for doctor services
- Medicare Part A deductible, which is $1,484 in 2021
- Medicare Part B deductible, which is $203 in 2021
- Part A copayment for inpatient care that exceeds 60 days
- transplant facility charges
Other costs vary depending on several factors, including:
- whether a person has another medical insurance plan
- whether a doctor accepts Medicare assignment
- the type of transplant facility that a person uses
Medicare only covers organ transplants that doctors perform in Medicare-certified facilities, but coverage is available for stem cell and corneal transplants in any suitable transplant center.
Medicare Part A usually only covers admissions that meet the 2-midnight rule, which means that a person must stay in a hospital for a minimum of 2 midnights. As transplants are intensive procedures, they typically satisfy this rule.
Medicare may grant coverage for shorter hospital stays on a case-by-case basis.
Transplants and end stage renal disease
Medicare covers people with end stage renal disease who require a pancreas transplant if the surgeon performs the procedure following a kidney transplant or also performs a kidney transplant at the same time.
In most cases, Medicare stops coverage for people with end stage renal disease 36 months after they receive a kidney transplant.
Medicare pays for immunosuppressive drugs indefinitely if an individual qualified for Medicare due to age or disability before their end stage renal disease diagnosis or after receiving a kidney transplant in a Medicare-certified facility.
People who cannot afford the out-of-pocket costs associated with a transplant have several options. A Medicare supplement plan can cover expected out-of-pocket costs, including copayments, coinsurance, and deductibles.
Some transplant centers offer payment plans to those needing financial assistance. These plans let transplant recipients pay in installments for the amount that Medicare does not cover.
People with limited income and resources may be eligible for help through Medicaid. Individuals must meet eligibility criteria for this government- and state-funded program that helps with a wide range of expenses.
Medicare covers a range of essential transplant services, including hospital services, immunosuppressant medications, and aftercare.
Most Medicare beneficiaries will still have some out-of-pocket costs. However, there are financial help options for those unable to cover these expenses.