What to Know About Medicare and Transplants
Medicare covers transplants and associated services under certain conditions.
Various costs are involved when it comes to transplants. For those unable to afford the costs associated with their transplant, Medicare supplement plans may help.
All transplants must be performed in Medicare-approved transplant centers.
In the event a Medicare beneficiary needs an organ transplant, they should be relieved to know that Medicare covers a variety of organ transplants, so long as their doctor declares the transplant to be medically necessary. Read on below to learn more about Medicare and transplants.
Does Medicare Cover Transplants?
Original Medicare covers some of the costs associated with getting a transplant. However, it is imperative transplant patients check with their insurance company to ensure specific doctors and hospitals are within the plan network.
To understand what Original Medicare pays when it comes to transplants, first it is important to discuss the various parts of Medicare. Original Medicare is comprised of Medicare Part A and Medicare Part B. Both of these parts help cover the costs of certain health care services.
Medicare Part A
Medicare Part A is Medicare’s hospital insurance, meaning it covers in-patient health care. Coverage includes:
Services for organ transplants
Labs, tests, and exams deemed medically necessary
Immunosuppressive (“transplant”) drugs
Procurement of organs
Stem cell transplants
Note: Certain conditions may apply. Transplant patients should consult their specific plan to fully understand what is covered.
Medicare Part B
Medicare Part B is medical insurance, covering outpatient health services. Coverage includes:
Doctors’ services associated with organ transplants (must be in a Medicare-certified facility)
Bone marrow and cornea transplants
Immunosuppressive (or “transplant”) drugs
Note: Certain conditions may apply. Transplant patients should consult their plan provider to fully understand what is covered.
Types of Transplants Covered
Medicare covers the following types of organ transplants:
Do note, an organ transplant must be done via Medicare-approved transplant programs. Organ transplant programs must be within a hospital that is contracted through Medicare.
Note: Learn more about organ transplants at the Centers for Medicare and Medicaid Services federal government website.
Kidney Transplant and End-Stage Renal Disease (ESRD) Medicare Rules
If a Medicare beneficiary has Medicare due to ESRD, there are some specific rules that apply. First, Medicare covers those with end-stage renal disease that needs a pancreas transplant if either of the following is true:
They must have previously had a kidney transplant
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 extended immunosuppressive coverage. This means, Medicare will cover 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.
Note: Learn more about ESRD and Medicare at this resource.
Transplants are incredibly intensive procedures that need appropriate aftercare and recovery time for both kidney transplant recipients and organ donors. Medicare will cover the following aftercare services for both parties:
Home health care
Nursing home care
While Medicare does cover transplants, there are still a number of costs associated with the procedures. This is not true for the living donor, however; Medicare will cover their costs fully.
Estimated costs for a transplant include:
20% of the Medicare-approved amount for doctor’s services
Part A deductible ($1,484 in 2021)
Part B deductible ($203 in 2021)
Transplant facility charges
Medicare beneficiaries are not responsible for paying the living donor for a kidney transplant. They also owe nothing for Medicare-certified laboratory tests.
Each patient’s overall cost will be different, which is why Medicare patients should always consult their doctor or health care provider about specifics. Other factors that contribute to out-of-pocket costs include:
What the doctor charges (and whether they accept the assignment)
The location of the test, item, or service
Out-of-pocket costs can be overwhelming, and also unaffordable for some. If that’s the case, there are several ways to go about getting them covered:
Medigap (MedSupp): Known as Medigap plans, these help patients cover out-of-pocket costs they could otherwise not afford to pay themselves. Essentially, these “fill in the gaps” of Medicare. This includes assistance with copayments, coinsurance, and deductibles.
Medicare Advantage (MA) Plans: Medicare Advantage plans, also known as Medicare Part C. MA plans are associated with lower monthly premiums and more comprehensive coverage than Original Medicare.
Medicaid-Medicare (Dual Eligibles) Program: Medicaid is a joint federal and state United States government program available to those who meet income and resource eligibility requirements. Medicaid and Medicare coverage can be combined, known as a “dual eligibles” program. Learn more about this program at this resource.
What Else To Know
Transplants must be performed in Medicare-approved transplant centers. Stem cell and cornea transplants can be done outside of Medicare-approved hospitals, however.
Medicare may consider a transplant as a hospital inpatient service under Part A. If this is the case, Medicare will then cover immunosuppressive drugs so long as the transplant was covered either by Medicare, or an employer or union group health plan needed to provide coverage before Medicare paid for the transplant. Part A is required at the time of the covered transplant, and Part B is required when immunosuppressive drugs are needed.
Patients must pay 20% of the Medicare-approved amount for prescription drugs. The Part B deductible also applies. Medicare Part D, which is Medicare’s prescription drug coverage, will cover immunosuppressive drugs if Part B doesn’t.
Before joining a Medicare Advantage Plan, those on a transplant waiting list should always do their research on the desired insurance plan. Patients should ensure their doctors, hospitals, and other healthcare providers and settings are within the insurance plan’s network. They should also review the plan’s coverage rules for prior authorization.
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