Does Medicare Cover Organ Transplants?
Medicare covers most of the hospital and medical costs for several types of organ and related transplants. This includes heart, lung, liver, kidney, pancreas and stem cell transplants. Medicare also covers most medical and hospital costs for the organ donor if the donor is still alive.
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 it’s performed in a Medicare-approved transplant center.
- Bone marrow (in certain conditions)
- Corneal (in certain conditions)
- Medicare Part A hospital insurance
- Hospital services for approved transplants
- Medically necessary tests, lab work and exams
- Immunosuppressive — or transplant — drugs (under certain conditions)
- Follow-up care
- Organ procurement
- Stem cell transplants (in certain conditions)
- Medicare Part B medical insurance
- Doctor’s services related to approved transplants
- Bone marrow transplants (in certain cases)
- Corneal transplants (in certain cases)
- Immunosuppressive drugs (in certain cases and with a Medicare-approved transplant)
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 plan’s network.
You may also need prior authorization from your Medicare Advantage plan’s administrator before you can go through with a transplant.
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.
- 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 (can vary depending on where it’s performed)
- Your Medicare Part B deductible ($203 in 2021)
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.
Understanding Transplant Costs
Transplants are complex surgical procedures and can be expensive. Their costs can vary based on the type of transplant, where you live and the facility that performs the procedure.
International consulting and actuarial firm Milliman, based in Seattle, estimated that the average billed costs of transplants in 2020 ranged from $32,000 for a corneal transplant to more than $1.6 million for a heart transplant.
|TRANSPLANT TYPE||ESTIMATED BILLED COST|
|Bone marrow, allogeneic (The patient is receiving healthy stem cells from a donor to replace their own damaged stem cells.)||$1,071,700|
|Bone marrow, autologous (Using healthy blood stem cells from your own body to replace diseased or damaged bone marrow.)||$471,600|
Medicare covers most of these costs for your transplant. And you may have options to cover your out-of-pocket expenses.
Medigap policies can cover copayments, coinsurance and deductibles. Check first to see exactly what your plan covers.
Some transplant centers offer payment plans that let you pay out-of-pocket costs in installments.
If you have limited income and financial resources, you may be eligible for Medicaid through your state Medicaid program.
What Is a Medicare-Approved Transplant Center?
Hospital transplant programs have to meet certain standards to become a Medicare-approved transplant center.
For approval, a transplant program has to be located in a hospital that accepts Medicare. It also has to meet what are called Conditions of Participation (CoP) for transplanting a particular type of organ — heart, lung, liver, kidney, pancreas or intestine.
Transplant programs have to submit specific data on its operations, its clinical experience and record of patient outcomes.
To gain Medicare approval as a transplant center, the transplant program must show its ability to perform successful transplants while delivering quality patient care. The level of patient care is measured by patient outcomes and the soundness of the program’s policies and procedures.
The standards are set by federal regulations published in the Federal Registry.
6 Cited Research Articles
- Sherrell, Z. (2021, January 11). Medicare and Transplants: What to Know. Retrieved from https://www.medicalnewstoday.com/articles/does-medicare-cover-transplants
- U.S. Centers for Medicare & Medicaid Services. (2020, May 21). Transplant. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Transplant
- Bentley, T.S. and Ortner, N.J. (2020, January). 2020 U.S. Organ and Tissue Transplants: Cost Estimates, Discussion, and Emerging Issues. Retrieved from https://milliman-cdn.azureedge.net/-/media/milliman/pdfs/articles/2020-us-organ-tissue-transplants.ashx
- U.S. Federal Register. (2007, March 30). Hospital Conditions of Participation: Requirements for Approval and Re-Approval of Transplant Centers To Perform Organ Transplants; Final Rule. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Downloads/trancenterreg2007.pdf
- U.S. Department of Health & Human Services, Office of Inspector General. (2006, September 28). Review of Organ Acquisition Costs Claimed by Certified Transplant Centers (A-09-05-00034). Retrieved from https://oig.hhs.gov/oas/reports/region9/90500034A.pdf
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Organ Transplants. Retrieved from https://www.medicare.gov/coverage/organ-transplants