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Medicare Kidney Transplant: Your Ultimate Guide

medicare kidney transplant

Medicare is available to people of all ages, not only those over the age of 65. Americans and legal residents of the U.S.A. of all ages who require dialysis or a medicare kidney transplant can benefit from the program. Medicare covers more than 90% of ESRD, which is another name for kidney failure, affects a lot of Americans. If you (or your parent or spouse) have worked long enough to be eligible for Medicare, it will cover the majority of your treatment costs, as well as some or all of your hospital stays, doctor visits, and other services. Furthermore, after you are enrolled in Medicare, it will cover other health issues unrelated to renal disease.

There are three components to Medicare:

  • Medicare Part A, B, and D

A new US law says that starting in 2023, Medicare patients who get a kidney transplant will not lose insurance coverage for immunosuppressant drugs that keep their bodies from rejecting the new organ. Lack of financial support for immunosuppressants is a leading cause of transplant rejection, with over 400 patients returning to dialysis each year.

This article discusses what Original Medicare covers and how it helps pay for services like kidney dialysis and kidney transplants.

Medicare Kidney Transplant: What Is It?

A healthy kidney from someone else is put into your body in a Medicare kidney transplant. When your own kidneys stop working, this donor’s kidney takes over. You could get a kidney from a donor who just died, or you could get a transplant from a living donor, like a family member. Checking the donor’s blood and tissue type for a match is essential to ensuring that your body accepts the new kidney. Medicare will pay for your kidney transplant only if it is performed in a hospital that is certified by Medicare to do kidney transplants.

Does Medicare Cover Kidney Transplant?

Medicare Parts A & B will pay for the vast majority of your kidney transplant care as long as it is administered in either the Medicare-approved transplant hospital or another Medicare-accepting facility.

Medicare Part A coverage for kidney transplant:

Inpatient care

  • Kidney registry cost
  • The cost of locating a suitable kidney for transplantation (No donor)
  • The complete care cost for the person who gave you a kidney (including care before, during, and after surgery)
  • Blood (blood components, units or whole of packed red blood cells, and donating blood)

Medicare Part B coverage for kidney transplant:

  • Doctors give pre-, during-, and post-transplant care.
  • Medical care for your organ donor while they are in the hospital
  • Immunosuppressive drugs or transplant drugs must be taken for a set period after a transplant patient is discharged from the hospital.

Medicare and Kidney Transplant: Options

Many people believe that Medicare and kidney transplant benefits are only available to those over the age of 65. However, ESRD patients of any age who need dialysis or a kidney transplant are also eligible. Let us talk about ESRD and how insurance can help you obtain the care you need at a price you can afford. You may have unique coverage needs and restricted plan alternatives, so let us talk about Medicare kidney transplants for ESRD.

End-Stage Renal Disease (ESRD)

ESRD causes permanent kidney failure, which demands survival for a kidney transplant or dialysis. Moreover, those with ESRD may be able to get Medicare coverage.

Despite of their employer’s size or health insurance coverage, patients with ESRD will have Medicare as their secondary insurer for 30 months. When a patient first enrolls in Medicare due to ESRD, coverage normally begins on the effective date of enrollment.

  • First, most people spend their fourth month on dialysis at a clinic specifically designed for that purpose.
  • Second, if specific criteria are met, Medicare coverage could begin during the first month of dialysis.

Also, training in home dialysis is started before the third month of dialysis. Furthermore, the patient intends to complete home dialysis training and perform self-dialysis treatments by the end of the third month.

Check to See Whether You Are Eligible

If you have failing kidneys, need frequent dialysis, or have had a kidney transplant, you can get Medicare at any age.

  • You’ve worked for the Railroad Retirement Board (RRB), the government for the required time, or Social security
  • You receive or are eligible for RRB payments or social security.
  • Or, you are someone’s child or spouse.

Medicare Coverage of Kidney Transplant with Immunosuppressive Drugs

Most patients with kidney failure benefit from kidney transplantation; however, a national organ scarcity and skewed incentives in the transplant system prevent many patients from receiving the treatment. A year-end legislation package included Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act. This act extends Medicare coverage of immunosuppressants for kidney transplants.

When is Medicare Primary?

Generally, Medicare will take precedence over other insurance policies if you have more than one. Group coverage through a smaller business, COBRA, inactive duty with TRICARE, and Medicaid are all examples. Primary insurance must be paid in full before secondary insurance kicks in.

Kidney Transplant Medicare Primary

For the first 30 months after receiving an ESRD diagnosis, an individual will continue to rely mostly on their employer-provided health insurance. They will automatically transition to Medicare after 30 months. Similarly, COBRA and Medicare Supplement insurance for the elderly are subject to this regulation.

Even if a kidney transplant cured end-stage kidney disease, Medicare coverage would end 36 months after the transplant. Medicare coverage won’t change if you’re qualified due to age or disability.

Approved Transplant Centers

National Coverage Determinations (NCDs) have changed the location of the list of Medicare-approved kidney transplant centers. Heart, liver, lung, and intestine transplant centers previously included on the NCD website, are now included in the comprehensive database of transplant facilities.

The kidneys, the pancreas, the liver, the lungs, the intestines, and the heart are all on the list. The lists also include information about where the hospital’s current certification came from, whether it was awarded by the NCDs or was mandated as part of the hospital’s participation requirements.

Applying for Medicare After Kidney Transplant

Wondering, “how long does medicare last after a kidney transplant?”   Let’s check it out.

The kidney transplant recipient’s Medicare coverage would cease 36 months after your kidney transplant if they were solely qualified for Medicare because of renal failure.

If your transplant is successful, meaning it lasts for 36 months without rejection, Medicare’s coverage for end-stage renal disease (ESRD) will expire. This means you will no longer receive coverage for dialysis and other therapies.

However, if you need to get another transplant or to begin dialysis within 36 months of your first one, treatment can be restarted.

You would continue to receive Medicare Parts A and B benefits as a normal beneficiary if you were already enrolled in Medicare before your ESRD diagnosis.

Does Medicare Pay for Kidney Transplants?

People who qualify for Medicare solely due to their extended history of renal failure will no longer receive coverage after 36 months, starting in the month after their transplant. Permanent Medicare coverage of transplant drugs is available if one of the following conditions is met:

You had Medicare Part A coverage before being diagnosed with ESRD; you had Medicare Part A coverage after receiving a transplant (in a Medicare-approved facility), or in addition to Medicare Part A coverage, you had private insurance.

What’s more, your costs will differ depending on the type of protection you need and the assistance you seek. The basic cost breakdown is as follows:

  • For any dialysis-related services that Original Medicare covers, beneficiaries will be responsible for paying 20% of the Medicare-approved sum. 
  • To cover the remaining cost, Medicare will contribute 20%.
  • You will not be charged for any Medicare-approved laboratory tests.
  • In most situations, from a blood bank, the hospital can obtain blood at no cost to you, and you will not be responsible for replacing it if it is lost or damaged.

How Much Does a Kidney Transplant Cost With Medicare?

When budgeting for a kidney transplant, it’s important to consider the associated costs.

Since a kidney transplant is considered life-saving, most insurance plans will pay for it. If you have insurance, paying for a kidney transplant will only involve out-of-pocket expenses like copayments for your doctor’s visits, medications, and lab work. Copayments for surgical and related procedures range from 10% to 50%.

However, patients not covered by insurance will have to pay more than $262,000 in the first year of expenditures, as reported by UNOS (United Network for Organ Sharing).

After surgery, you won’t require more than the standard post-op prescriptions. Immunosuppressants are the term for these sorts of drugs. All of these things will aid in your body accepting the new kidney.

Popular anti-rejection drugs include Cellcept, Prograf, and Prednisone. Cellcept has a total projected monthly cost of roughly $1,064. Prograf, on the other hand, is expected to cost about $1,340 each month. Also, Prednisone is about $12 a month to take altogether. The following prices are estimates that will change based on the dosage needed and the drugstore chosen.

Always factor in the cost of testing, evaluation, surgery, medication, and care after the transplant.

Pre-transplant medical care in the hospital, with your primary care physician, with any necessary specialists, and with any necessary laboratory tests could add up to a significant sum. Furthermore, the total can rise rapidly due to the accumulation of these charges. How long a patient stays in ICU determines costs. Again, this is highly conditional. Some patients may receive treatment in the ICU before obtaining a transplant. While it is standard practice to transport all surgical patients straight to the intensive care unit (ICU), there may be exceptions.

All of the money needed for the transplant can come from one place. Having health insurance is a fantastic illustration of this. Health insurance might pay for procedures like organ transplants. As for the rest, you can use your savings or sell some of your properties to cover the costs. When you consider information from multiple sources, you can have more confidence in your findings.

Additional Expenses

After the procedure, you will have additional expenses for what we’ve already covered. The cost of Kidney transplantation and the involvement of medicare will add another layer of complexity to the already high price tag.

While your new kidney is functioning, you must take medication to prevent rejection. According to the American Kidney Fund, the annual cost of these medications can exceed $17,000.

Medicare and private insurance don’t cover all of the expenses associated with a kidney transplant, including extensive laboratory tests; organ recovery; hospital stay and recovery; fees for surgeons and other operating personnel; anaesthesia; physical and rehabilitation therapy; and anti-rejection drugs.

Bottom Line

If you have chronic renal failure and need a kidney transplant, Medicare coverage will expire 36 months later. To illustrate, let’s say that before or after your ESRD diagnosis, you were Medicare-eligible for a kidney transplant. Medicare will still pay for transplant medicines if this happens. Hospitalization, immunosuppressant drugs, and follow-up treatment are all covered by Medicare following a transplant.

There will still be some out-of-pocket expenses for the vast majority of Medicare recipients. Those who otherwise could not pay for such costs may qualify for financial assistance. Having End-Stage Renal Disease will not affect Medicare coverage if you are eligible for Medicare due to disability or age.

Reach out today at NewMedicare and get your quotes now!

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