Medicare and Transplants

Around 95 people receive a new organ every day. You may know someone who has been an organ donor or recipient, or maybe you are! Along with many things in healthcare, organ transplants have come a long way since they were first introduced in the 1950s. From donors to dialysis, there is a lot to learn about transplants, including insurance coverage. While many individuals receive a new organ every day, it does not shy away from the fact that it is a serious and expensive procedure. Understanding more about the cost ahead of time will help you prepare for what is to come. Whether you are already a Medicare recipient or not, if you are in need of a specific transplant, this information will apply to you.

If Under 65 and Obtaining Medicare:

If under 65 and obtaining Medicare because of ESRD (End-Stage Renal Disease), then Medicare will cover these transplants:

  • Kidney
  • Kidney/Pancreas
  • Pancreas

If you have ESRD and are not a Medicare beneficiary due to age or disability, then your coverage will be under Original Medicare, Parts A and B. You may also have the option to join a Medicare Special Needs Plan if one is available in your area. These plans are a specific Medicare Advantage Plan available to an individual, in this case, under certain medical conditions. They will cover the same services that Medicare Parts A and B cover, and it includes Prescription Drug Coverage (Part D). If you are eligible for Medicare due to ESRD, then you still must meet the set deductible before your coverage begins.

While Medigap policies are offered to individuals over 65 in all states, there are select states that have them available for individuals under 65. These plans vary from state to state. If you are interested in obtaining a Medigap policy and are under 65 with ESRD, contact your local State Health Insurance Assistance Programs (SHIP). 

Part A Coverage

There are many questions to ask yourself before undergoing a transplant, such as, “What hospital should I have my transplant take place?” or “How long will I be in the hospital?” All these questions can leave someone wondering how much all this will cost them. For most inpatient services, this is where your Part A coverage with Original Medicare comes in. For a kidney transplant in particular, Part A will cover the kidney registration fee, finding the proper kidney if no donor, the full cost of coverage for your donor, laboratory tests, inpatient services, and blood, if a transfusion is needed. Think of your Part A under Medicare as your hospital coverage. It will cover part of all your services while in the hospital.

Part B Coverage

While the focus of the transplant is the surgery, itself, there are many other factors that an organ recipient needs to be aware of. After every transplant, patients begin to take immunosuppressive medications, or anti-rejection medications. These will prevent your body from rejecting the new organ and, in return, are lifesaving. It is important to note that if you obtain Medicare because of ESRD, then your Medicare coverage will either end 36 months after the month of your transplant or 12 months after the month you stop dialysis treatment. This also means that your coverage for the immunosuppressive medications will also end unless you reach Medicare age or become disabled. Your Part B will also cover doctors’ services for you and your kidney donor during their hospital stay whether before surgery, after surgery, or care after surgery.  

How do I enroll in Medicare if I have ESRD?

If you have ESRD and need to enroll in Medicare, you can go to their website at www.ssa.gov, visit your local office, or call at (800) 772-1213.

When does my Medicare coverage begin?

Once you have enrolled in Medicare, your coverage will begin on the first day of the fourth month of your dialysis treatment. If you begin dialysis in January, then your Medicare coverage will begin in April.

If your transplant is scheduled, but delayed, your Medicare coverage will begin two months before the month of your transplant. For example, if your transplant is scheduled for May, but then moved to August, your Medicare coverage will begin in June since it is two months before the month of your transplant.

If Already a Medicare Beneficiary:

If obtained Medicare due to age or disability, then you will also have coverage on these transplants:

  • Liver
  • Lung
  • Heart
  • Heart/Lung
  • Intestines

If you are already a Medicare beneficiary, these “Part A” and “Part B” terms are nothing new to you. In transplant circumstances, you are still responsible for 20% of the cost, while Medicare covers 80%. If enrolled in a Medicare Advantage Plan, your costs could vary. It is important to review your plan information or call your provider.

If you are needing assistance in covering the remaining 20% of your costs, a Medigap plan can help cover the balance as long as the service has been approved by Medicare. If you are interested in obtaining a Medigap plan to help you fill the "gaps" in coverage, contact a MWG Senior Services agent! They can walk you through the steps to help get the coverage you need.  

Part A Coverage

If already a Medicare beneficiary, Part A coverage with Medicare will cover in-patient hospital costs needed for your transplant. This coverage will pay for the hospital stay expenses and the surgery itself. While Medicare does not cover 100% of the costs, it will cover many things needed for the recipient for before and after surgery. Part A will also cover part of the costs for a stem cell transplant under certain conditions.

Part B Coverage

Already being a Medicare beneficiary has its perks when it comes to coverage on immunosuppressive medications. Unlike coverage if you are enrolling in Medicare because of ESRD, Medicare will pay indefinitely for your immunosuppressive medications if you had Part A at the time of your transplant and Part B when getting prescriptions filled.

Dialysis

When your kidney is functioning properly, it filters and removes the waste particles and excess fluid in your blood. Many patients that have ESRD, may undergo dialysis. Dialysis is a treatment used to filter the blood when your kidney function is low. It also helps control blood pressure and regulates certain chemicals in your blood. This treatment allows blood to be removed from the body, circulated through a dialysis machine, and returned to the body. It takes between three to ten hours and must be done three to six times per week. Whether you must undertake dialysis is determined on a case by case basis. For some, it is not required to complete dialysis before a kidney transplant. If your kidney is from a deceased donor, it may take longer for it to function. In this case, your doctor may advise you to undergo dialysis until the new kidney begins to work.

There are many options for those in need of dialysis. If you decide to utilize a Medicare approved hospital, then your Part A will help cover costs for dialysis. For services performed at a Medicare-approved dialysis facility or any at-home dialysis services, such as training for you or someone assisting you, are covered under your Part B. Your Part B will also cover any supplies or equipment needed during at-home dialysis such as dialysis machines, alcohol, wipes, scissors, and rubber gloves. Most injectable medications and oral forms used for at-home dialysis and laboratory tests are also covered under your Part B. It is important to note that transportation to a dialysis facility is not covered under Medicare in most cases.

Tips

  • Be sure to verify that your facility is Medicare-approved.
  • Keep records of all bills, forms, and payments. If you do not have copies of these, you can find them on the MyMedicare.gov website.

I am not in need of a transplant, but how can I help those who are?

According to organdonor.gov, only three in 1,000 organs will be recovered in a way that allows for donation to a recipient. While only 60% of Americans are registered organ donors, the numbers are upsetting for those in need of a transplant. One person can possibly donate eight organs to potentially save lives. The number of people on the waiting list for a transplant raises rapidly every year, while the number of donors grows slowly. To learn more on becoming an organ donor, visit www.organdonor.gov.