Does Medicare Part A And Part B Cover Kidney Transplant Surgery
The medical expenses involved in a kidney transplant can be extensive and you will need medical care before and after your surgery. Medicare generally covers you for all stages of your kidney transplant. If you have a living donor, generally Medicare will cover his medical expenses involved with organ donation as well. Medicare Part A and Medicare Part B generally cover different expenses involved in a kidney transplant.
Medicare Part A coverage of kidney transplants typically includes:
- Kidney registry fee
Medicare Part B coverage of a kidney transplant typically includes:
- Immunosuppressive prescription drugs that lower the bodys ability to reject the kidney transplant
- Doctors care for all stages of the kidney transplant surgery
- Doctors care for your donor during his hospital stay
- Follow-up care after the kidney transplant
Medicare Part B coverage of immunosuppressive prescription drugs is generally for a limited time after you leave the hospital following a kidney transplant. For long-term coverage of immunosuppressive prescription drugs you may need Medicare Part D coverage.
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.
What Are Your Costs For Transplants Under Medicare
You are responsible for certain costs coinsurance, deductibles and certain facility fees associated with your transplant in addition to what Medicare covers.
Your Transplant Costs Under Medicare
- 20 percent of the Medicare-approved amount for immunosuppressive drugs
- 20 percent of the Medicare-approved amount for your doctors services
- Various costs for transplant facility charges
- Your Medicare Part B deductible
You pay nothing out-of-pocket to the living donor for a kidney transplant and nothing for any Medicare-certified laboratory tests.
While most transplants have to be performed in a Medicare-approved transplant facility to be covered by Medicare, stem cell and corneal transplants can be performed in nontransplant facilities.
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State High Risk Insurance Pool
Many states offer a high-risk health insurance pool to provide access to coverage to individuals with serious pre-existing medical conditions. Typically the premiums are higher, and the coverage may be more limited. Ask your transplant center social worker or financial coordinator if your state has a high-risk insurance pool or learn more now >
Has The Aca Expanded Medicares Immunosuppressive Drug Coverage For Kidney Transplant Recipients
I had a conversation with my doctor last week. . He asked me if I had heard anything during my last trip to Washington, D.C. about an extension of coverage through the ACA to kidney transplant patients of the immunosuppressive drug coverage beyond the 36 month period that currently exists. This rang a bell in the back of my brain, so I decided to check it out.
Every transplant patient or transplant candidate knows the current status of the law. If you are a kidney transplant recipient, you must take medications the rest of your life to prevent rejection of your transplanted kidney. Medicare pays for the transplant and immunosuppressive drugs for 36 months post-transplant, but coverage of these critical medications stops unless the beneficiary is Medicare-aged or Medicare-disabled. Here is where the gap in coverage comes in if youre under 65 and you have received a transplant, you are not age-eligible, nor are you considered disabled because after you have a transplant, you are no longer Medicare-disabled. Coverage for anti-rejection drugs for those patients that fall into the gap is limited to 36 months. The catch is that anti-rejection meds are very expensive. One newspaper article I read reports that one patient was paying as much as $1,750 a month, and the National Kidney Foundation estimates that Medicare pays $124,643 for a first year transplant patient, and then pays $24,612 a year primarily for anti-rejection meds thereafter.
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Renal Disease Treatment Coverage Provided By Medicare
While Medicare does not cover transportation to dialysis, it generally provides coverage for certain treatments, medications and kidney transplant procedures. Transplant services covered by Medicare Part A include:
- Kidney registry fee
- Expenses of finding appropriate kidneys for transplant when donors are not available
- Complete care costs for kidney donors
- Inpatient services at Medicare-certified hospitals
Transplant services included by Medicare Part B include:
- Doctors services before, during and after kidney transplant surgery procedures
- Immunosuppressive transplant drugs
- Blood transfusions
Recipients on Original Medicare plans may receive coverage for dialysis in-hospital and at Medicare-certified dialysis facilities. Plans may also cover the costs of dialysis equipment for at-home use.
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How Long Does Medicare Last After A Kidney Transplant
If you are a Medicare beneficiary suffering from End-Stage Renal Disease or kidney failure, you should keep the following information in mind regarding a kidney transplant.
- If you only became eligible for Medicare because of kidney failure, your Medicare coverage will end 36 months after your kidney transplant.
- Medicare will only cover your kidney transplant if its performed in a hospital that is Medicare-certified to do kidney transplants.
- Medicare will continue to cover your transplant drugs with no time limit if you were already eligible for Medicare before you were diagnosed with kidney failure. Your Medicare coverage of immunosuppressive drugs will also continue without a time limit if you became eligible for Medicare due to age or other disability after the transplant took place or if you had private insurance that paid primary to your Part A coverage.
What Are The Extra Costs
According to the American Kidney Fund, the patients have to take anti-rejection drugs for the rest of their lives, and this will cost around $17,500 per year.
In the unfortunate situation of a transplant failure, the recovery treatment cost could go up to hundreds of thousands of dollars. For instance, the Center for Medicare & Medicaid Services says that the cost of treatment after a transplant failure, also known as graft failure, will be around $142,000. Around 55% of kidney transplants fail within ten years.
Option A: Indefinite Benefits For Esrd Recipients With Coterminous Immunosuppressant Coverage For All Other Medicare Beneficiaries
In 1991, the Institute of Medicine committee recommended:
that Congress eliminate the three-year limit on Medicare eligibility for ESRD patients who are successful transplant recipients and authorize an entitlement equal to that of ESRD patients who are treated by dialysis, and that coverage of immunosuppressive medications for kidney transplant patients be made coterminous with the period of a patient’s entitlement.
This option would place renal transplant recipients on the same footing as ESRD patients receiving dialysis. Such a policy would facilitate those able to return to the workforce doing so and would relieve potential employers of the burden of providing health insurance for this high-cost group. In the 1991 report, potential costs for such an approach, to include those recipients who had already lost benefits, was estimated to be $415 million$500 million annually for 55,000 renal transplant beneficiaries by 1995. Costs for indefinite immunosuppressant coverage alone were projected to have reached approximately $300 million annually by 1995. These cost estimates did not address any potential offsets, which might include the cost of graft failure and retransplantation due to noncompliance, reduced disability benefits, and reduction of Medicaid spending for those eligible for both Medicare and Medicaid.
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Kidney Transplant And End
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
Its 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.
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
- severe bronchiectasis
- sickle cell disease
Doctors might also suggest a transplant if they feel that it will improve a persons 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 individuals 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
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How Does Medicare Cover Transplants
There are two parts to Original Medicare:
- Medicare Part A helps pay for inpatient services received in a hospital or skilled nursing facility . For this reason, it is sometimes called hospital insurance.
- Medicare Part B covers outpatient services like doctor visits, mental health care, durable medical equipment, and lab work. It is sometimes called medical insurance.
If Medicare helps pay for your organ transplant, it will also cover related preoperative and postoperative services like lab work, tests and screenings, organ procurement, and follow-up care. Medicare Part B will also cover certain medications, such as transplant drug therapy and immunosuppressive drugs.
Medicare Coverage For Lung Transplants
Medicare Part A helps cover lung transplant costs in a Medicare-approved hospital. Part B covers the doctors services necessary for the transplant, like office visits.
Lung transplant coverage also includes necessary laboratory tests and exams, follow-up care, and immunosuppressive drugs under certain conditions.
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How Much Does Medicare Pay For Heart Transplants
Hospital costs related to your heart transplant are typically covered by Medicare Part A.
Doctor services related to your transplant are typically covered by Medicare Part B.
Even if Medicare covers your heart transplant, you are generally responsible for a portion of the costs. Some of these costs include:
- Medicare Part A deductible: The Part A deductible is $1,556 per benefit period in 2022.A benefit period begins the day you are admitted to the hospital and ends when youve been discharged for at least 60 days. If youve been out of the hospital for more than 60 days and are admitted again, a new benefit period begins. You must pay your Part A deductible before Medicare will pay its share for covered hospital services.
- Medicare Part A coinsurance: After you meet your Part A deductible, you are typically responsible for paying Part A coinsurance costs.
- Days 1-60 spent in the hospital: $0 coinsurance for each benefit period
- Days 61-90: $389 coinsurance per day of each benefit period
- Days 91 and beyond: $778 coinsurance per each lifetime reserve day after day 90 for each benefit period
- Beyond lifetime reserve days: you are responsible for all costs
Lifetime reserve days are 60 additional days of coverage that can be used over the course of your life. For each lifetime reserve day, Medicare pays all covered costs except for the daily coinsurance. Once you use these 60 days, they cannot be renewed.
Potential Modifications To The Medicare Program
In 1972, Congress addressed the issue of ESRD care with the intention to provide access to life-saving therapy for all who needed it where the costs of treatment were beyond the means of practically all individuals. In the 1991 IOM report, it was noted that the Congress, via PL 95292 in 1978, the National Organ Transplant Act of 1984, OBRA 1986, and the Transplant Amendments Act of 1990, had consistently encouraged organ transplantation. In the face of increasingly successful outcomes, and given that Medicare had made the commitment to fund the transplant procedure itself , the previous committee saw no scientific basis supporting termination of access to care and immunosuppressant drugs at an arbitrarily defined time. They recognized that renal transplant recipients were not cured, and that ongoing care was as essential to survival as the thrice-weekly dialysis treatments for non-transplanted ESRD patients. Now, almost a decade later, rapid advances in the science of transplantation have made current policy even less consistent with the original congressional intentions. As the issue of long-term care for Medicare-covered transplant recipients is revisited, what changes might restore equilibrium between policy and practice?
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How Much Does A Kidney Transplant Cost
In most cases, kidney transplant surgeries are covered by health insurance policies. If you have health insurance then you will have to pay the doctor visit, lab exams, and prescription medicine out of your pocket, plus the coinsurance of 10% to 50% for surgery and other procedures. All of these could reach the yearly out-of-pocket maximum.
In case you dont have health insurance you will have to pay around $262,000 or even more for a kidney transplant, including the costs of donor matching, pre-transplant screening, the surgery itself, care after surgery, and the drugs needed in the first six months after surgery. After that, the anti-rejection drugs will cost you around $17,500 per year.
From Vimo.com, a website that compares the costs of health care, we find out that the average cost of a kidney transplant is around $144,000 and if it is negotiated through a health insurance company, it will be around $34,000.
Transplant Living website states that the total expenses with a kidney transplant starting from the month before surgery until the end of the first six months post-surgery will be around $262,000, including more than $17,500 for medication. These expenses include the costs of the pre-surgery medical examinations, the surgery itself, hospitalization for any complications, care after surgery, and the anti-rejection medicine.
Medicare And Medicare Supplement Insurance Coverage For Esrd Treatments
Medicare Part A and Part B provide different dialysis and transplant-related coverage. Medicare Part A provides inpatient hospital care coverage and Medicare Part B provides medical care coverage.
Medicare Supplement insurance coverage will help you pay for some of the out-of-pocket costs associated with that coverage. This may be important to you if you use dialysis, since it will help pay for all of Medicare Part B co-payments that are required for most dialysis-related services.
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Will I Be Charged The Full Part B Monthly Premium That I Currently Pay
No. Since your Medicare coverage after 36 months is limited to immunosuppressive drugs, the monthly premium will be equal to 15 percent of the monthly rate for Medicare beneficiaries age 65 and over. The amount will be determined by the U.S. Department of Health and Human Services in September of each year.
An Enormous Win For Patients Saving Millions Of Dollars For Medicare
The action won wide praise from the clinical community.
This bipartisan, common-sense policy will directly improve the lives of hundreds of transplant patients and help increase the number of transplants available to patients, said Anupam Agarwal, MD, president of the American Society of Nephrology , in a written statement.
The bills passage represents an enormous win for patients and the fulfillment of a top ASN priority. The society stands ready to work with policy makers to implement this legislation, he said.
Michelle Josephson, MD, chair of the ASN Policy and Advocacy Committee, added: I am thrilled to see this critical legislation pass Congress. I have cared for too many patients who have lost their kidney transplants because they could not afford their immunosuppressive medications after Medicare ceased coverage at 36 months, only to return to more-expensive dialysis.
And Marwan S. Abouljoud, MD, president of the American Society of Transplant Surgeons, noted in a separate statement: Medicares limitation on immunosuppressive drug coverage was never able to be justified medically, economically or ethically, and I am thankful Congress has finally taken action on this much-needed reform.
The new law specifies that Medicare will cover the cost of immunosuppressive drugs indefinitely if no other coverage is available.
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Are Immunosuppressive Drugs Covered By Medicare
Immunosuppressive drugs are covered by Medicare for various medical reasons, such as:
- To stop the body from rejecting donor organs
- To treat autoimmune conditions, such as:
- Alopecia areata
There are several types of immunosuppressive drugs. Some are taken orally, and others are given via infusion or injection. You may need to take one or more every day.
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What Transplants Does Medicare Cover
Original Medicare Medicare Part A and Part B covers most costs associated with a transplant under certain conditions and only if its performed in a Medicare-approved transplant center.
Transplants Medicare Covers
Hospital and Medical Services Original Medicare Covers
- Medicare Part A hospital insurance
- Hospital services for approved transplants
- Medically necessary tests, lab work and exams
- Immunosuppressive or transplant drugs
- Stem cell transplants
- Medicare Part B medical insurance
- Doctors services related to approved transplants
- Bone marrow transplants
- Corneal transplants
- Immunosuppressive drugs
Medicare plans sold by private insurers may also help you pay for a transplant. These include Medicare Advantage, Medicare Part D prescription drug and Medigap plans.
While Medicare Part A and Part B both cover certain immunosuppressive drugs needed for transplants, a Medicare Part D plan can also help you pay for these medications.
Medigap or Medicare Supplement plans may also cover some of your out-of-pocket expenses.
Medicare Advantage plans are required to cover everything Original Medicare covers. But your plan may offer other benefits. If you are on a transplant waiting list and considering a Medicare Advantage plan, check first to make sure your doctors and hospitals are part of the plans network.
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