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Does Medicare Pay For A Kidney Transplant

Can You Appeal A Denial Of Coverage For Home Dialysis Equipment Or Services

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Sometimes, Medicare may deny coverage for a service or equipment related to your home dialysis. An appeal is the action you can take if you disagree with the decision. For example, you can file an appeal if Medicare or your Medicare Advantage plan:

  • Denies a request for a service, supply, item, or prescription drug that you think should be covered by your plan

  • Denies a request for payment of a healthcare service, supply, item, or prescription drug you already have received

  • Denies a request to change the amount you are required to pay for a healthcare service, supply, item, or prescription drug

  • Has stopped providing or paying for all or part of a healthcare service, supply, item, or prescription drug you believe you still need

Appeals tend to be the most successful when your doctor is supportive by deeming the service, supply, item, or prescription drug medically necessary or if you have reason to believe that there was a processing error that led to your coverage denial. Medicare has issued an official booklet that explains the appeals process in detail.

Preemptive Transplantation And The Ckd Paradigm

Dissemination of the KDOQI staging and treatment guidelines for CKD in 2002 has already exerted a profound impact on the practice of medicine in the United States . Designed to promote early recognition and intervention in patients with what might be termed subclinical kidney disease, it spells out new metrics for monitoring kidney function and guidelines for therapy. The KDOQI guidelines recommend that patients with eGFR < 30 ml/min/1.73 m2 be prepared for dialysis and transplantation but do not describe the preemptive transplant option in detail.

Impact of duration of time undergoing dialysis on allograft survival at 10 yr after transplantation for recipients of kidneys from living and deceased donors .

Given the current imbalance between supply and demand of kidneys for transplantation and proposed modifications in national kidney allocation policy of organs from deceased donors that are likely to favor those who are already on dialysis , it must be recognized that the future of preemptive transplantation is tightly intertwined with availability of LD. This inescapable corollary implies that early education of patients and families must incorporate a timely discussion of issues surrounding LD transplantation. This requirement underscores recent emphases on donor education, health, and autonomy already initiated in the transplant community .

Making Preemptive Transplantation Normative: Overcoming Barriers With Training And Education

Although benefits of preemptive transplantation have been documented in the literature for almost a decade, its continued rarity in clinical practice indicates the existence of substantial barriers to implementation. These include impediments at each step in the transplantation process, many of which have been previously identified but not yet remedied .

At the physician level, generalists must become better informed regarding recognition of CKD and appropriate timing of referral to a nephrologist. Nephrology fellowship training must include adequate exposure to transplantation issues, with emphasis on defining candidacy and helping patients prepare for transplantation. Continuing education for nephrologists must include state-of-the-art transplant teaching. Having an adequate number of nephrologists available to see and care for patients early in the CKD pipeline will likely require more manpower in the field. Financial structures within practices must allow adequate time and staffing for transplant teaching and posttransplantation care .

Comparison of Medicare reimbursement to a nephrology practice on an annual per-patient basis for care of a patient on dialysis versus posttransplantation office visits at three different levels of care. In most practices, transplant recipients are seen much less often than on a monthly basis .

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Medicare Immunosuppressive Drug Coverage For Kidney Transplant Recipients

End-stage renal disease is substantial and permanent loss in kidney function. Persons with ESRD require either a regular course of dialysis treatment or a kidney transplant to survive. The Medicare program provides coverage for health care services for the vast majority of individuals diagnosed with ESRD, regardless of age.

In 2010, roughly 489,000 Medicare beneficiaries received ESRD-related servicesâless than 1% of the total Medicare population. According to the United States Renal Data System , in 2010, Medicare expenditures for the ESRD-related services totaled $32.9 billion, or roughly 6.3% of total Medicare expenditures.

Individuals who have received a kidney transplant usually require immunosuppressive drugs for the rest of their life to minimize the risk of their immune system rejecting the donor kidney. In 2010, Part B expenditures for immunosuppressive drugs totaled $345 million. Under Part B, Medicare provides payment for immunosuppressive drugs based on manufacturersâ reported average sales price , for each drug, plus a 6% handling and storage payment. Since 2009, the ASP for commonly used immunosuppressive drugs has decreased by over 50%âmost likely due to the use of generics.

If Youre Younger Than 65 Years Old

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If you are an adult who has ESRD and are under 65 years old, you must meet one of the following criteria to be eligible for Medicare:

  • youve worked the required amount of time
  • your already receive Social Security or Railroad Retirement Board benefits
  • you have a spouse who meets either of the above criteria

Children with ESRD must have a custodial parent or guardian who has paid Medicare taxes for at least 40 quarters to be eligible for Medicare.

If you only have Medicare because you have ESRD, your coverage will end 12 months after you stop dialysis treatment or 36 months after you have a kidney transplant.

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Medicare Pays For A Kidney Transplant But Not The Drugs To Keep It Viable

The federal government will pay more than $100,000 to give someone a kidney transplant, but after three years, the government will often stop paying for the drugs needed to keep that transplanted kidney alive.

Constance Creasey is one of the thousands of people who find themselves caught up by this peculiar feature of the federal kidney program.

Creasey started kidney dialysis about 12 years ago after her kidneys failed. That meant going to a dialysis center three times a week, for three hours per session. .

The first three years of dialysis was hard. I walked around with this dark cloud. I didnt want to live, I really didnt, she says.

Being dependent on these blood-cleansing machines was physically and emotionally draining. But she stuck it out for 11 years. Medicare pays for dialysis, even for people under the age of 65. It also pays for kidney transplants for people with end-stage renal disease.

Finally, a year and a half ago, transplant came. I was a little apprehensive but I said OK. And I call her Sleeping Beauty, thats my kidneys name.

Creasey, a 60-year-old resident of Washington, D.C., no longer needs to spend her days at a dialysis center. She has enough energy for a part-time job at a home furnishing store and time to enjoy lifes simple pleasures.

I was able to do my favorite thing go to the pool and I was just loving it because its like I had no restrictions now, she says.

I Have An Employer Group Health Plan

  • If you are eligible for Medicare, your EGHP will be your primary insurance for 30 months after starting dialysis or having a kidney transplant. This is called a coordination period. After 30 months, your EGHP will become your secondary insurance and Medicare will become primary.
  • When should I apply for Medicare?

    You can apply for Medicare when you first start dialysis or wait and apply closer to the end of the 30-month coordination period. Once you apply you will be responsible for the monthly Part B premiums.

    If you are planning to have a transplant and want Medicare to help pay for your immunosuppressant medications you will need to apply for Medicare part A and B when you become eligible.

  • Insurance Choices for Dialysis and Transplant Patients with Private Insurance

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Should Doctors Game The Transplant Wait List To Help Their Patients

Being dependent on these blood-cleansing machines was physically and emotionally draining. But she stuck it out for 11 years. Medicare pays for dialysis, even for people under the age of 65. It also pays for kidney transplants for people with end-stage renal disease.

“Finally, a year and a half ago, transplant came. I was a little apprehensive but I said OK. And I call her Sleeping Beauty, that’s my kidney’s name.”

Creasey, a 60-year-old resident of Washington, D.C., no longer needs to spend her days at a dialysis center. She has enough energy for a part-time job at a home furnishing store and time to enjoy life’s simple pleasures.

“I was able to do my favorite thing go to the pool and I was just loving it because it’s like I had no restrictions now,” she says.

But there is still a dark cloud on Creasey’s horizon. Medicare’s kidney program currently pays for a large share of the expensive drugs she needs to take twice a day to prevent her body from rejecting the transplanted kidney. But under federal rules, that coverage will disappear three years after the date of her transplant.

“I have a year and a half to prepare, or save,” she says. “How am I going to do this?”

She’s already paying copays, premiums and past medical bills. She says she sleeps on the floor because she considers buying a bed a luxury she can’t afford.

“It’s probably about 30 percent of people who find themselves in a troublesome spot at this 36-month mark,” he says.

How To Pay For An Organ Transplant

Medicare Options for Dialysis Patients

Surgery can be very expensive and organ transplant surgery is among the most costly procedures. For people facing an expensive procedure, whether or not it’s a transplant, you may need to raise funds in advance for treatment.

The initial testing required for a patient to be placed on a waiting list for a transplant or to be cleared for surgery can alone cost tens of thousands of dollars, even if the patient is not hospitalized during the process.

It is not uncommon for the cost of major surgery and subsequent extended hospitalization to result in a bill that exceeds $500,000. Unfortunately, the expenses do not end with surgery the cost of medications in the year after surgery can be thousands of dollars a month.

Ideally, a patient will have primary insurance to pay the majority of the expenses and a secondary form of insurance to pay the remaining expenses.

Even with excellent insurance coverage that pays 80% of the total bill, the remaining 20% can exceed $100,000 from the surgery alone. With secondary or supplemental insurance coverage, the remaining 20% may be paid by the insurance company rather than the patient.

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Fundraising To Pay For A Transplant

Some transplant patients approach public service organizations for help in paying the costs of transplantation. Civil service organizations may be willing to donate to help a patient get a life-saving surgery. Other patients hold fundraising events, such as walkathons, or appeal to their friends, family, and fellow community members to help raise the money they need. Before launching a fundraising campaign, it’s best to check with your city or county governments, a legal advisor, or your transplant team about legal and financial laws and guidelines.

The financial coordinators at transplant centers may be able to provide help with locating organizations that can contribute to your fundraising efforts.

Some patients have great success with online fundraising, using websites such as GoFundMe.com to share their story.

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.

Your Transplant Costs Under Medicare

  • 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
  • Your Medicare Part B deductible

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.

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Who Is Eligible For The Indefinite Coverage

Anyone who meets the following criteria are eligible for indefinite coverage of their transplant immunosuppressive medications under Medicare Part B:

  • Received a kidney transplant from a Medicare-approved facility.
  • Was eligible for Medicare at the time of their transplant and applied for Medicare prior to the transplant . It does not matter if Medicare was the primary or secondary payer to other insurance.
  • Does not have Medicaid.
  • Does not have other public or private health insurance with an immunosuppressive benefit.

Public insurance includes Medicaid, Department of Veterans Affairs coverage, or TRICARE . Private insurance examples include a group health plan , employer-based plan, coverage under the Affordable Care Act, or individual health insurance plan.

What Are The Risk Factors For Kidney Disease

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According to NIDDK, the main risk factors of chronic kidney disease include:

  • Diabetes
  • Cardiovascular disease
  • Family history of kidney disease

NDDK says that kidney disease affects people of all races and ages. African Americans, American Indians, and Hispanics can be at high risk for kidney failure, mostly because of higher rates of diabetes and high blood pressure.

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Do You Have More Questions About Medicare Coverage For Kidney Transplants

Im happy to discuss your options with you. You can schedule a phone call or request information to read in an email by clicking the appropriate link below. To view some plans in your area you may qualify for, click the Compare Plans button.

New To Medicare?

Becoming eligible for Medicare can be daunting. But don’t worry, we’re here to help you understand Medicare in 15 minutes or less.

What Home Dialysis Costs Are Not Covered By Medicare

While Medicare covers most of the essential services that are required for home dialysis, there are a few items that are not covered. These include:

  • Paid dialysis aides to help you with home dialysis

  • Payment for time lost from work for you or the person who may be helping you during home dialysis training

  • A place to stay during your treatment

  • Blood, or packed red-blood cells, for home dialysis unless this is part of a doctors service

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Paying For An Expensive Surgery With Private Insurance

Private insurance is coverage that is not sponsored by the government the patient or a spouse typically obtains a private insurance policy from his or her employer. In some cases, particularly for people who are self-employed, private insurance can be obtained outside of the workplace. In that case, the patient pays the insurance premium.

Depending on your plan, private insurance may assume a good portion of the total cost of an organ transplant. However, most insurance plans have a maximum or “cap” on the amount that the company will pay. This cap may be met or exceeded in the standard care provided during the course of an organ transplant.

What Health Plans Does Medicare Offer

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Medicare has two main ways to get coverageOriginal Medicare, which includes Part A and Part B, or a Medicare Advantage Plan, also called Part C. You can also choose to have prescription drug coverage through Medicare Part D.

Most people with kidney failure are not allowed to join a Medicare Advantage plan. However, beginning in 2021, the 21st Century Cures Act will allow people with ESRD to choose a Medicare Advantage plan instead of Original Medicare. Medicare Advantage plans may limit where you get care, but they cap out-of-pocket costs. With Original Medicare, there is no cap on out-of-pocket costs, but you can get care anywhere that Medicare is accepted.

You can find out more about the Medicare health plans by visiting Medicare.gov and searching on ESRD, then clicking on Signing up for Medicare if you have ESRD.

Other Medicare health plans are available that have special rules or are for specific groups of people. Medicare offers more information about these alternate plans online.

Learn more about Medicare benefits, rules, and coverage details at Medicare.gov or by calling 1-800-MEDICARE .

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Paying For An Organ Transplant With Personal Funds

Many patients cannot afford to pay for the full cost of organ transplant surgeryor even an insurance deductibleusing personal funds. Most people waiting for an organ transplant have financial difficulties, especially if their illness has caused them to be placed on disability.

This is not uncommon, and many patients explore other options to help them fund their procedure.

Transplants And End Stage Renal Disease

Medicare covers people with end stage renal disease who require a pancreas transplant if the surgeon performs the procedure following a kidney transplant or also performs a kidney transplant at the same time.

In most cases, Medicare stops coverage for people with end stage renal disease 36 months after they receive a kidney transplant.

Medicare pays for immunosuppressive drugs indefinitely if an individual qualified for Medicare due to age or disability before their end stage renal disease diagnosis or after receiving a kidney transplant in a Medicare-certified facility.

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Which Home Dialysis Costs Does Medicare Cover

Original Medicare, Part A and Part B, will cover many home dialysis services and supplies for people with end-stage renal disease, including:

  • Home dialysis training

  • Home dialysis equipment and supplies such as dialysis machine, water treatment system, basic recliner, alcohol, wipes, sterile drapes, rubber gloves, and scissors

  • Some home support services, which may include visits by trained dialysis workers to check equipment and water supply

  • Outpatient dialysis treatments and doctors services in your home

  • Most drugs

For doctors that treat you outside of the hospital, including your kidney specialist, Medicare usually pays a monthly amount. After you pay the Part B yearly deductible, Medicare will cover 80% of this monthly amount, while you pay the remaining 20% or coinsurance. Doctors also are sometimes paid per day if services are provided for less than a month.

Home dialysis requires training, and the length of time needed for training varies depending on factors such as the type of dialysis, the equipment, and the protocols of your care team. Medicare coverage will pay for home dialysis training by a Medicare-certified home dialysis training facility, and this includes instruction for you and the person helping you with your home dialysis treatments. Medicare also will compensate your kidney doctor for supervising the training, and, after you pay the Part B yearly deductible, Medicare pays 80% of the fee while you pay the remaining amount.

  • Home dialysis machine

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