Transplantation is usually recommended for two reasons: it will save a life of a person or it will improve a person`s life quality. Doctors recommend a transplant if someone`s organ/s are not working as they should or not working 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. Doctors might also suggest a transplant if they feel that it will improve a person’s quality of life. Almost 40,000 organ transplants took place in the United States in 2019, according to the United Network for Organ Sharing (UNOS). In 2023, there are over 106 000 people on the UNOS waiting list.
People with certain diseases may qualify for transplants, including, but not limited to, those with:
- bone marrow disease
- chronic obstructive pulmonary disease (COPD)
- cystic fibrosis
- multiple myeloma
- severe bronchiectasis
- sickle cell disease
MEDICARE COVERAGE FOR ORGAN TRANSPLANTATION
While Medicare doesn’t set any criteria for covered organ transplants, organ transplant programs generally do have eligibility requirements. Once a doctor has determined that a Medicare beneficiary requires an organ transplant, Medicare will cover the following transplants:
- Stem cell
Medicare covers only transplants performed through Medicare-approved transplant programs. These approved organ transplant programs must exist within hospitals that are contracted to provide services under Medicare. The only exception to this rule is that cornea and stem cell transplants don’t need to be performed in a Medicare-approved transplant center.
Here is a breakdown of Medicare coverage regarding organ transplantation by Medicare Parts:
For a person receiving a transplant and a living person donating an organ, Medicare Part A covers:
- blood transfusions and processing
- essential lab tests and examination
- hospital services associated with organ transplants
- immunosuppressive medications that doctors provide in the hospital
- organ sourcing and procurement
- follow-up care
- stem cell transplants
- kidney registration fee, if applicable
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.
Then Medicare Part B covers further transplant-related costs, including:
- corneal transplants
- doctor`s services associated with organ transplants
- immunosuppressive medications if they are necessary
When it comes to Medicare Part C (Advantage) plans, they have the same coverage level as Original Medicare (Part A and B together). So with Part C, you have coverage for everything previously mentioned under Part A and Part B. Some Part C plans also cover prescription drugs and possibly even additional health perks, like fitness memberships and meal services. Medicare Advantage Special Needs Plans (SNPs) are a type of plan that offers coordinated services for people with chronic or disabling conditions.
Medicare Part D helps cover prescription drugs needed for organ transplantation. While Part D coverage varies by plan, all Medicare prescription drug plans must cover immunosuppressant drugs. These medications, which weaken your immune system to make it less likely that your body will reject a new organ, are required for transplantation. Most prescription drug plans also cover other medications that may be necessary for organ transplant recoveries, such as pain relievers, antidepressants, and more.
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, and nursing home care.
END-STAGE RENAL DISEASE TRANSPLANTATION RULES
If a Medicare beneficiary has Medicare due to ESRD, there are some specific rules that apply. First, Medicare covers those with an end-stage renal disease that needs a pancreas transplant if they have previously had a kidney transplant or if the surgeon performs a kidney transplant at the same time as the pancreas transplant.
It’s important to know that Medicare coverage usually ends for those with ESRD 36 months after they receive a kidney transplant. However, Medicare will pay for immunosuppressive drugs indefinitely so long as the patient becomes eligible for Medicare because of age or disability prior to their ESRD diagnosis OR following a kidney transplant in a Medicare-approved facility.
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 Medicare-approved amount for doctor services
- Medicare Part A deductible, which is $1556 in 2022
- Medicare Part B deductible, which is $233 in 2022
- Part A copayment for inpatient care that exceeds 60 days
- transplant facility charges
There are some other costs that can vary regarding several factors, such as if a person has another medical insurance plan except Medicare if a doctor accepts Medicare Assignment, which type of transplant facility the person uses, and lastly, location.
Dr. Susan Johnson is a Medicare Health Advisor with extensive knowledge and experience in health insurance, particularly Medicare. She has spent over 15 years working in various healthcare settings, including hospitals, clinics, and private practices.
As a Medicare Health Advisor, Dr. Johnson specializes in helping people navigate the complex world of health insurance, including original Medicare, Medicare Advantage, Medicare supplements, and Medicare Part D. She is committed to providing personalized guidance to her clients, helping them make informed decisions about their coverage and reduce their healthcare costs.