Medicare Organ Transplant Coverage
Key Takeaways
- Medicare will cover most medically necessary organ transplants.
- Medicare will usually cover 80% of costs related to organ transplants.
- Examples of organ transplant surgeries that Medicare covers include kidneys, lungs, liver and heart.
- The transplant must occur at a Medicare-certified transplant center.
- Medicare Part BMedicare Part B is medical insurance that covers Medicare-approved services — such as medically necessary treatment and preventive services — and certain other costs, like durable medical equipment. Medicare Part B is part of Original Medicare. will also typically cover immunosuppressive drugs to prevent transplant rejection.
Organ transplants are life-saving, yet costly, procedures. If you have Medicare and require an organ transplant, your Medicare plan will usually cover you as long as your surgery is at a facility that accepts Medicare. Because an organ transplant can be an extensive surgery that often requires taking lifelong immune system-suppressing medications, it’s important to understand what you may pay under Medicare.
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Does Medicare Pay for Transplants?
Medicare pays for organ transplants, including those of the heart, intestines, kidneys, liver, lungs and pancreas. You must get the surgery in a Medicare-certified facility. Other organ transplants, such as cornea or bone marrow transplants, may require more specific conditions for a person to qualify.
An organ transplant and its costs are often more than just the surgery itself. Medicare covers the following aspects surrounding an organ transplant:
- Physician’s services, including doctor and surgeon services (the doctors must accept Medicare)
- Laboratory testing, medical exams and other related tests
- Immunosuppressive medications designed to keep your body from “rejecting” the new organ
- Follow-up care
After you meet your Part B deductible, Medicare will usually pay 80% of the Medicare-approved amount for transplant services. This means you are responsible for the remaining 20%, which may include surgeon services, operating room fees and hospital fees. Your costs may be different if you have a Medicare Advantage plan.
You typically do not have to pay for laboratory tests that are Medicare-certified. Living donors (such as for a kidney) also do not have to pay any costs for their surgery or hospital stay for donating a kidney.
Kidney transplant coverage
Medicare will cover kidney transplant costs to you and a living donor, should you have one. If you do not, they will cover costs to help find a kidney from organ donors or other donor registry lists.
The following is a table that explains some of the costs and coverages under Medicare for a kidney transplant.
Medicare Part A covers:
- Inpatient services at a hospital that accepts Medicare
- Kidney registry fee
- Laboratory testing for you and a potential kidney donor
- Costs to find a donor kidney
- Costs of care for the kidney donor (including inpatient care if there are complications from the surgery)
- Blood products
Medicare Part B covers:
- Doctor’s services for the kidney transplant surgery
- Doctor’s services for your kidney donor
- Transplant (anti-rejection) medications
- Blood products, if required post-surgery when you have been discharged
If you qualified for Medicare based solely on having end-stage renal disease instead of based on age, your Medicare benefits will end 36 months after the month of your transplant. If you have a qualifying disability, however, your Medicare coverage may continue.
Heart transplant coverage
According to the Journal of the American College of Cardiology, an estimated 30.3% of heart transplant recipients in 2016 were Medicare beneficiaries. Medicare covers heart transplant procedures at Medicare-certified transplant centers.
Much like other organ transplant coverage, Medicare covers the costs of testing, facilities, inpatient stays and medications for a heart transplant.
Liver transplant coverage
Medicare will pay for liver transplants, providing a patient undergoes the transplant procedure at a Medicare-certified transplant facility. A survey of liver transplant patients from 2001 to 2017, conducted by The American Journal of Managed Care, estimated that 37,893 of 177,862 patients were under Medicare coverage.
Medicare will cover the costs of the liver transplant under Part A, with the subscriber paying 20% of the remaining costs.
Lung transplant coverage
Medicare offers coverage for lung transplants. From 2005 to 2011, Medicare provided coverage for an estimated 3,128 lung transplants. This number was about 32.2% of all lung transplants during the study’s time period. The average total costs at a high-volume transplant center were $131,352. This number includes the surgery costs, inpatient stay costs, medications and more.
Medicare Part A pays for most costs related to lung transplant surgery while Medicare Part B will typically cover doctor’s fees, as well as some immunosuppressive or transplant drugs.
In addition to costs related to the surgery, there are significant medical costs related to lung transplant in the first year after surgery. Medicare costs average $236,450 in the first year after surgery, according to the Annals of the American Thoracic Society.
Cornea transplant coverage
Medicare will generally cover cornea transplant surgery. Another name for cornea transplant surgery is keratoplasty.
An exception to cornea transplants versus other organ transplants is that the surgery does not have to take place in a Medicare-certified transplant center. However, you would still need to ensure your surgeon and facility accept Medicare or Medicare Advantage before proceeding with the surgery.
Sources
- Organ transplants. Medicare.gov.
- Kidney transplants. Medicare.gov.
- Effect of Transplant Center Volume on Cost and Readmissions in Medicare Lung Transplant Recipients. ATSJournals.org.
- Outcomes of Liver Transplantation by Insurance Type in the United States. The American Journal of Managed Care.
- Emerging Trends in Financing of Adult Heart Transplantation in the United States. Journal of the American College of Cardiology.
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