Section 3: Kidney Transplants
What is a kidney transplant?
A kidney transplant is a type of surgery that’s done to put a healthy kidney from another person into your body. This new kidney does the work that your own kidneys can no longer do. You may get a kidney from someone who has recently died, or from someone who is still living, like a family member. The blood and tissue of the person who gives you the kidney must be tested to see how well they match yours so that your body won’t reject the new kidney.
To be covered by Medicare, your kidney transplant must be done in a hospital that’s approved by Medicare to do kidney transplants.
If you have a problem with the care that you’re getting for your transplant, you have the right to file a grievance (complaint). See here, “Filing a grievance (complaint),” for more information.
Kidney transplant services covered by Medicare
Medicare covers the following transplant services and pays part of their costs: Service or supply covered by Medicare Part A:
■ Inpatient services in an approved hospital
■ Kidney registry fee
■ Laboratory and other tests needed to evaluate your medical condition*
■ Laboratory and other tests needed to evaluate the medical condition of potential kidney donors*
■ The costs of finding the proper kidney for your transplant surgery (if there’s no kidney donor)
■ The full cost of care for your kidney donor (including care before surgery, the actual surgery, and care after surgery)
■ Any additional inpatient hospital care for your donor in case of problems due to the surgery
Service or supply covered by Medicare Part B:
■ Doctors’ services for kidney transplant surgery (including care before surgery, the actual surgery, and care after surgery)
■ Doctors’ services for your kidney donor during their hospital stay
■ Immunosuppressive drugs (for a limited time after you leave the hospital following a transplant). More info. See here for information about Medicare Prescription Drug Plans.
Service or supply covered by Medicare Part A and Part B:
■ Blood (whole or units of packed red blood cells, blood components, and the cost of processing and giving you blood). More info.
To find out what you pay for these services, see here.
* These services are covered whether they are done by the Medicare-approved hospital where you will get your transplant, or by another hospital that participates in Medicare.
Note: Buying or selling human organs is against the law. Therefore, Medicare doesn’t pay for the kidneys used for transplant.
Transplant drugs (cal ed immunosuppressive drugs)
What are immunosuppressive drugs?
Immunosuppressive drugs are transplant drugs used to reduce the risk of your body rejecting your new kidney after your transplant. You’ll need to take these drugs for the rest of your life.
Important: You must meet the conditions listed here for Medicare to cover your immunosuppressive drugs.
What if I stop taking my transplant drugs?
If you stop taking your transplant drugs, your body may reject your new kidney, and the kidney could stop working. If that happens, you may have to start dialysis again. Talk to your doctor before you stop taking your transplant drugs.
How long will Medicare pay for transplant drugs?
If you’re entitled to Medicare only because of permanent kidney failure, your Medicare coverage will end 36 months after the month of the transplant.
Medicare won’t pay for any services or items, including immunosuppressive drugs, for patients who aren’t entitled to Medicare.
Medicare will continue to pay for your immunosuppressive drugs with no time limit if you:
■ Were already entitled to Medicare because of age or disability before you got ESRD
■ Became entitled to Medicare because of age or disability after getting a transplant that was paid for by Medicare, or paid for by private insurance that paid primary to your Part A coverage, in a Medicare-certified facility
If you’re entitled to Medicare only because of permanent kidney failure, your Medicare coverage will end when your 36-month period is over.
What if I can’t pay for the transplant drugs?
Transplant drugs can be very costly. If you’re entitled to Medicare only because of permanent kidney failure, your immunosuppressive drugs are only covered for 36 months after the month of your transplant. If you’re worried about paying for them after your Medicare coverage ends, talk to your doctor, nurse, or social worker. There may be other ways to help you pay for these drugs. See here to learn more about other health insurance options.
Special information about pancreas transplants
If you have ESRD and need a pancreas transplant, Medicare covers the transplant if one of the following applies:
■ It’s done at the same time you get a kidney transplant.
■ It’s done after a kidney transplant.
Note: In some rare cases Medicare may cover a pancreas transplant even if you don’t need a kidney transplant.
If you’re entitled to Medicare only because of permanent kidney failure, and you have the pancreas transplant after the kidney transplant, Medicare will only pay for your immunosuppressive drug therapy for 36 months after the month of the kidney transplant. This is because your Medicare coverage will end 36 months after a successful kidney transplant if you only have Medicare due to permanent kidney failure.
If you were already entitled to Medicare because of age or disability before you got ESRD, or if you became eligible for Medicare because of age or disability after getting a transplant, Medicare will continue to pay for your immunosuppressive drugs with no time limit.
What YOU pay for kidney transplant services
The amounts listed in this section are for transplant services covered in Original
Medicare. If you’re in a Medicare Advantage Plan, your costs may be different. Read your plan materials, or call your plan to get information about your costs.
Do I have to pay for my kidney donor?
No. Medicare will pay the full cost of care for your kidney donor. You don’t have to pay a deductible, coinsurance, or other costs for your donor’s hospital stay.
Hospital services
If you have Original Medicare, in 2012 you pay:
■ $1,156 deductible per benefit period
■ $0 for the first 60 days of each benefit period
■ $289 per day for days 61–90 each benefit period
■ $578 per lifetime reserve day* after day 90 each benefit period (up to 60 days over your lifetime)
■ All costs for each day after the lifetime reserve days
For Medicare-approved care in a skilled nursing facility, you pay:
■ $0 for the first 20 days each benefit period
■ Up to $144.50 per day for days 21–100 each benefit period
■ All costs for each day after day 100 in the benefit period
To find out what you pay for other Part A and Part B services, visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
*In Original Medicare, lifetime reserve days are additional days that Medicare will pay for when you’re in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
Doctors’ services
In Original Medicare, you must pay the Part B yearly deductible ($140 in 2012). After you pay the deductible, Medicare pays 80% of the Medicare-approved amount. You must pay the remaining 20% coinsurance.
Important: There’s a limit on the amount your doctor can charge you, even if your doctor doesn’t accept assignment. If your doctor doesn’t accept assignment, you only have to pay the part of the bill that is up to 15% over the Medicare-approved amount.
Clinical laboratory services
You pay nothing for Medicare-approved laboratory tests.