Am I a Transplant or Donor Candidate?

Planning ahead and being well informed will help a patient to maximize their coverage for transplant services. Often there are limitations or exclusions for certain services. Patients should discuss their coverage for transplant services with their insurance company.

Note: The information on this page is intended to assist patients in understanding some basic insurance information as it relates to transplantation. This website is not intended to cover all aspects of insurance requirements for transplantation, but to provide a helpful overview of things to consider.

Financial Coordinators begin working with the patient and the insurance company during the pre-transplant evaluation phase to verify patient coverage. Transplantation is a very complex and costly treatment for organ failure. It is important for each patient to understand their coverage, their potential out of pocket expenses, and have a long term plan to cover transplant services.

Following transplantation, taking immunosuppressive (anti-rejection) medications is vital to the success of the organ transplant. These medications can cost between $5000 and $7000 monthly and must be taken for the life of the transplant. It is essential to have adequate insurance to cover this expense, or have the resources to pay for the medications. Many insurance companies also offer a mail order option for medications, which can lower out-of-pocket costs. When prescription coverage is limited, careful planning is essential and patients may need to have funds set aside prior to the transplant. Fund-raising through organizations such as www.HelpHopeLive.org or www.transplants.org (National Foundation for Transplants website) might be a helpful option. Some drug companies offer programs to assist needy patients with their medications. The Transplant Social Worker or Transplant Specialty Pharmacy can provide additional information about how to apply for these programs.

While patients may have adequate health insurance coverage, there may be services their insurance will not cover, such as:

• Transportation to and from the transplant center for frequent follow-up visits
• Temporary lodging and meals for family members during and after the transplant
• Parking fees for visits to the transplant center
• Insurance premiums, co-pays, and deductible amounts
• Possible loss of income while out of work for the transplant
• Child care

When planning ahead to receive and organ transplant, there are some important things to consider that may change the patient's coverage:

• Reaching the maximum limit the insurance company will pay
• Divorce or separation from a spouse that can lead to cancellation of coverage on the spouse's policy
• Changes that may impact the insurance coverage: change in job status due to health, lay-off, change in student status, or other causes
• Changes in the patient's insurance policy that can lead to increased co-pays and/or deductibles
• Children reaching age 26 and no longer being covered under their parents insurance or state funded health plans at age 21

Health Maintenance Organizations (HMOs) require patients to have a referral from their primary care physician (PCP) prior to seeing a specialist. A referral is documentation from the Primary Care Provider that they are 'referring' the patient to a specialist. The patient must obtain the referral prior to the date of the appointment. Without a referral the HMO will not pay for the visit and the patient will be responsible for the bill.

In addition to PCP referrals, some insurance companies require prior plan authorization to begin the transplant process. The patient should call their insurance company prior to making the initial appointment to see what is required by their insurance company.

Many insurance companies are part of a larger network of hospitals and physicians. Insurance companies often contract with transplant networks to manage their transplant cases. Some insurance networks will not approve transplants at Michigan Medicine, and will require the patient to use a transplant center within their network, even if the preferred center is in another state.

If a patient's insurance changes while they are on the transplant list, it is important to call the Transplant Financial Coordinator to report the change. Organ transplants require written approval from the insurance carrier prior to the transplant. If a change in insurance has occurred and no authorization is in place, the patient is responsible for full payment of all services rendered. The authorization process is lengthy; the sooner an insurance change is identified the faster the patient can be re-authorized through the new insurance carrier. In addition, it is recommended that patients contact the Transplant Financial Coordinator prior to making any changes during an open enrollment period.

When a patient begins dialysis or has a kidney transplant, they may be eligible for Medicare. Even if they have group health insurance, Medicare can help cover the costs that insurance does not pay.

If a patient enrolls, they must be sure to have both part A and part B. Please read the booklet called "Medicare Coverage of Kidney Dialysis and Kidney Transplant Services." The patient may contact the Transplant Financial Coordinator to obtain a copy of the booklet or for further information. Coverage through Medicare is at 80% for the life of the transplant as long as the patient meets the following criteria:

1. The patient must be enrolled in Medicare at the time of the transplant. Patients can apply for retroactive coverage only following a kidney transplant.
2. The patient must continue to be eligible for Medicare due to age or disability.

If a patient qualifies for Medicare only because they have end-stage renal disease, the Medicare coverage will end 36 months after a kidney transplant and the patient won't qualify for coverage unless they regain eligibility at a later time.

Patients can discuss their transplant coverage options and request any changes by contacting a Medicaid Representative at 1-888-367-6557. Patients with Medicare and a Medicaid monthly "spend down" amount will benefit by enrolling in a Medigap program, and may be required to do so depending on the amount of the monthly deductible.