Financing a Transplant

Funding Sources

Common funding sources to help with the costs of transplants include:

Note: This information is only a brief summary and is not intended to provide complete information. Ask your transplant financial team and your insurance provider or employee benefits officer for the latest information or help.

Insurance

You or your family may have health insurance coverage through an employer or a personal policy. Although many insurance companies offer optional coverage for transplant costs, the terms and benefits of insurance vary widely. That's why it's important to read your policy carefully and contact your insurance company if you have questions about how much of your costs they will pay, including your lab tests, medications and follow-up care after you leave the hospital.

Regardless of how much your insurance covers, it is important to know that you are responsible for any costs not paid by your insurance, unless you have made other arrangements. If you are responsible for paying any or all of your insurance premiums, be sure to pay them on time so that you do not lose your insurance.

Transplant center social workers and financial coordinators can also help you with the information you need. They can contact your insurance company to check on your benefits and explain your coverage in more detail.

Insurance "Caps"

Many insurance policies state a total amount of money that will pay out in your lifetime, also referred to as a "cap." After the insurance company pays this amount, they are not required to pay additional benefits. Some policies also put a cap on how much they will pay for a particular procedure or treatment, such as a transplant or the total amount of drugs per year. Even after the actual transplant, the ongoing cost of care may exceed the cap. Because the amount of the cap varies greatly depending on the individual policy, it is important to be familiar with the terms of your insurance cap and keep track of how your insurance dollars are spent.

Experimental and Investigative Procedures

If your transplant center asks you to be involved in any experimental procedures or studies, be sure to ask your center or insurance company if your insurance policy will cover the payment. It is important to know that you do not have to agree to be involved in any experimental procedures or investigational studies. If you still have questions, contact your employer's benefits office or your state insurance commissioner.

Tips

  • Keep copies of all medical bills, insurance forms and payments (or canceled checks).
  • Ask your insurance company about pre-certification or using a specific provider.
  • Follow the rules set forth by your insurance company so that your benefits will not be decreased.
  • Always keep a log (who you talked to, date and time and questions answered) of your conversations with anyone in the hospital's billing office or your insurance company.
  • Make sure to keep your transplant center informed about your insurance, especially if you have more than one insurance company.
  • For more helpful tips, see the Financial Q&A.

Other Sources of Insurance

Call your state insurance commissioner to see if these plans are available in your state:

  • Certain people with pre-existing conditions, who have been denied insurance coverage, qualify for high-risk pools. High-risk pools are only offered in some states and premiums can be from 50% - 200% higher than standard policies. Benefits are usually more limited than standard policies and have limited coverage for outpatient medication.
  • Some states offer guarantee issue, which requires insurers to offer individual coverage regardless of pre-existing conditions. All individual policies are usually more costly in these states.
  • Federal fallback requires insurance companies to offer coverage to patients whose existing COBRA benefits are ending. It is only available in some states and provides patients a choice of the two most popular insurance plans that the insurance company offers. The premium is the same as everyone else within the policy.

Medicare

Medicare is a health insurance program funded by federal tax money. It is available to people who are 65 or older, disabled or have end stage renal disease(ESRD).

Medicare does not always pay 100% of your medical expenses. Payment is usually based according to a set fee, which may be less than the actual cost of a service. You are therefore required to pay deductibles and various other expenses, such as co-pays. Because of these additional expenses, it may be necessary to buy a private insurance policy, called a supplemental or "Medigap" policy, to help pay for some of the expenses Medicare does not cover.

To receive full Medicare benefits for a transplant, your transplant center must be a Medicare approved facility that meets Medicare standards for the number of transplants they do and the quality of patient outcomes. You may also have to meet certain Medicare conditions, such as age and the medical reason you need a transplant.

Types of Medicare Coverage

Medicare offers these plans:

  • Medicare Insurance (Part A)
    Offered free to those who qualify, this insurance covers care in hospitals as an inpatient, critical access hospitals, skilled nursing facilities, hospice care and some home health care. It offers coverage for kidney transplants in a Medicare-approved facility and coverage for certain heart, lung, liver and heart/lung transplants (if you already have Medicare due to age, disability, or kidney failure) in Medicare approved facilities.
  • Medicare Insurance (Part B)
    This insurance requires that you pay a premium. It covers doctors' services, outpatient hospital care and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. It also pays for part of the cost of anti-rejection drugs, if you remain eligible for Medicare and were entitled to Medicare at the time of transplant.
  • Medicare Insurance (Part D)
    Since January 1, 2006, Medicare Part D can help you pay for your prescribed drugs that are not covered by Part A or Part B if you join a plan. Anyone with Medicare can join, even if you’ve had a transplant.

    Medicare Part B will still cover part of the cost of anti-rejection drugs if you had Medicare Part A when you got your transplant, you had your transplant in a Medicare approved transplant program, and you have Medicare Part B. If you didn’t have Medicare Part A when you got your transplant or if you didn’t have your transplant in a Medicare approved transplant program, your anti-rejection drugs have not been covered by Part B, but may be covered under Part D since January 1, 2006.

Please discuss your options with your transplant financial coordinator or contact Medicare directly. You can also find out more about how Medicare helps pay for kidney dialysis and kidney transplant services. For further information, contact your local insurance agent, Social Security office, transplant financial team member or the Medicare Hotline.

Medicare
Phone Number (800) 633-4227
Web Address: www.medicare.gov

Medicaid

The Medicaid Program provides medical assistance for certain individuals and families with low incomes and resources. It is funded and administered through a state-federal partnership. Individual states can decide who is eligible, determine what benefits and services to cover (not all states cover transplants) and set payment rates.

For more information, contact your local social security office, transplant team or the Medicare Hotline.

Medicaid Categories

The two possible categories of need under Medicaid are:

  • Categorically Needy
    Sates must cover "categorically needy individuals," which typically includes low income families with children, pregnant women, infants and children with incomes less than a specified percent of the Federal poverty level, qualified Medicare beneficiaries and individuals receiving SSI.
  • Medically Needy (Spend Down)
    Offered in certain states, this Medicaid category allows you to subtract your medical expenses from your income so that your income will be less than a specified percent of the Federal poverty level. "Spend down" is the process of using medical expenses to reduce your income to the level that you would be eligible for Medicaid.

TRICARE (formerly CHAMPUS)

TRICARE is a regionally managed health care program for active duty and retired members of the uniformed services, their families and survivors. Patients must receive pre-authorization, based on a summary submitted by the attending transplant physician, from TRICARE and meet TRICARE selection criteria. TRICARE may share the cost of heart, lung, heart/lung, heart-kidney, liver, kidney, liver/kidney, kidney/pancreas and living-related liver donor transplants for patients with end-stage organ disease (ESRD).

For further information regarding TRICARE transplantation benefits, contact the health benefits advisory at your nearest military health care facility or contact:

TRICARE
Phone Number (303) 676-3526
www.tricare.osd.mil

Prescription Drug Assistance Programs

Many drug companies provide medications for patients who are financially needy. Call the following companies for more information:

Roche Patient Assistance Program (Cellcept)
Phone Number (800) 772-5790

Novartis Patient Assistance Program (Cyclosporine)
Phone Number (888) 455-6655

Novartis Transplant Reimbursement Information (Neoral)
Phone Number (877) 952-1000

Astellas Patient Assistance Program for Organ Transplant (Prograf)
Phone Number (800) 477-6472

Abbott Patient Assistance Program (Gengraf)
Phone Number (800) 633-9110

Wyeth Patient Assistance Program (Rapamune)
Phone Number (877) 472-7268

For a full directory of programs, including who is eligible and what drugs are covered, visit the Pharmaceutical Research and Manufacturers of America Web site.

Questions To Ask

  • Am I eligible for prescription drug assistance? If so, for how long?
  • Do I need a referral from my transplant team to be eligible?
  • How long does it take to apply and process paperwork to get started with your program?
  • How do I receive the drugs?

Veterans Administration

Although it has become more difficult to become eligible without a service-connected disability, you may be eligible for VA benefits if you have been honorably discharged from the military. If you first became ill while in the service or are indigent, you may be also eligible to receive a transplant at a VA Medical Center. Some veterans may also receive medications funded by the VA. For more information, contact your local Veterans Hospital or VA office.

Charitable Organizations

Charitable organizations offer a range of support, from providing information about diseases, organs and transplants, to encouraging research into these diseases and treatments.

Also, although it is very unlikely that one organization can cover all of the costs for an individual patient, some organizations provide limited financial assistance through grants and direct funding. For example, an organization may only be able to help with direct transplant costs, food and lodging or medication costs.

Advocacy Organizations

Advocacy organizations advise transplant patients on financial matters. If you agree to a financial arrangement with an advocacy organization, it is important to make sure that the funds are available in a manner that suits your needs. You may even want legal assistance in reviewing a written agreement before signing. Your bank can also help you review the arrangement.

Every advocacy organization should be able to provide supporting information and background documentation to prove they are legally recognized to help those in need. Brochures and other background information should never serve as substitutes for these documents. Ask advocacy organizations to provide you with copies of the following documents:

  • a current federal or state certification as a charitable, non-profit organization
  • a current by-laws, constitution and/or articles of incorporation
  • a financial statement for the preceding year, preferably one that
  • an audit report from an independent organization
  • references

Fundraising Campaigns

Public fundraising is often used to help cover transplant expenses not paid by medical insurance. Before you begin seeking donations, it may be necessary to check with your city/county governments, legal advisor or transplant team about the many legal and financial laws and guidelines.

If you decide to use public fundraising as a way to cover your expenses, you may want to contact local newspapers, radio or television stations to help support your cause. In addition, try to enlist the support of local merchants and other sponsors to promote or contribute to your events. Your friends, neighbors, religious groups, local chapters of volunteer or service groups and other community groups may also be able to help.

It is also very important to understand that the funds you raise only be used for your transplant-related expenses and donated money sometimes has to be counted as taxable income. In cases in which money must be counted as income, you may lose your Medicaid eligibility.

For more helpful tips, see the Financial Q & A.




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