Paying for an organ transplant
Transplant Center financial case managers
Understanding organ transplant insurance coverage
How insurance covers organ aquisition
Cost of living donation
Paying for services, medicines and equipment after transplant
Types of insurance
Paying for costs not covered by insurance
Fundraising
Paying for transplant medication
Patient assistance pharmaceutical programs
National Foundation for Transplant
Other programs
Appeals
Insurance issues checklist  
Special insurance considerations for kidney transplant
Renal Medicare
State renal programs

Paying for an organ transplant
There are costs associated with transplant surgery and with a patient’s life-long medical care after transplant. These costs raise important and necessary questions. Our financial case managers are here to help you to become familiar with your health insurance coverage. They can also provide you with information about available financial assistance. This will help you to understand your options for transplant. All transplant patients have different insurance coverage depending on their work or financial situation. 

Transplant Center financial case managers
For questions regarding the financial aspects of transplantation at University of Minnesota Medical Center and University of Minnesota Children’s Hospital, please contact a transplant financial case manager.

• If you are a patient, please call  800-688-5252
• If you are a health care professional, please call  800-888-8642

Understanding organ transplant insurance coverage
What your insurance pays for depends on your specific policy coverage plan. Your insurance policy manual or your insurance representative should explain any costs of transplant not covered by your insurance company. You will have to pay for these costs out of pocket. Some insurance policies may pay 100 percent of expenses, while others pay 80 percent or less.

There may be a cost to you if your insurance company does not approve a transplant at University of Minnesota Medical Center, or if your policy has limits on transplant services. Some insurance companies will only pay for a transplant if it is done at a center with which they have a contract. The insurance benefits representative or someone in your employer's human resources department may be able to help you understand your specific coverage and limitations. Your insurance company phone number is usually on the back of your insurance identification card.

You should always inform the Transplant Center of the your current insurance coverage and of any changes or new coverage you may have. This includes insurance that is dropped or terminated.

Once we know that you would like to undergo transplantation at University of Minnesota Medical Center, one of our financial case managers will check on your insurance coverage. They will make sure that your care will be covered at our center.

How insurance covers organ acquisition
In most cases, your insurance company's transplant coverage will pay for the aquistion of an organ. This is true whether the organ comes from a living donor or from a deceased donor. Some companies may have limits, however, on how much they will pay for organ acquisition.

Costs of living donation
A living donor will not be billed for transplant-related medical expenses. However, insurance will not pay for the donor's travel, time off work, childcare, etc. Sometimes donors may be eligible for grants to pay for these costs. Donors may discuss the details of living donation with one of our donor coordinators.

Paying for services, medicines and equipment after transplant
After your transplant, you will need financial resources or insurance coverage to stay healthy. Clinic visits, expensive anti-rejection medications, blood tests, etc., will all be needed for the years after transplant. If you have any questions about paying for these expenses, check with your insurance company before the transplant. They should be able to advise you about coverage of these costs.

Types of insurance

Employer Private Insurance
If you or your spouse is working, chances are an employer covers your health insurance. Get to know your specific coverage options and choose a plan that best meets your transplant needs.

If your employer offers you an HMO (Health Maintenance Organization) you should know which providers, services and pharmacies are in its network. You will probably need to get referrals from your HMO primary care clinic for specialty services such as transplants. If you do not have referrals, you may have to pay all or part of the costs for medical services.

If you or your spouse stops working, you may be able to continue employee coverage for an additional 18-29 months. This is known as the COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage law. According to this federal law, an employer with 20 or more employees must offer continuation of group health coverage. The employee is responsible for paying premiums after terminating employment. Learn more about your COBRA options from your employee benefits office or contact the Pension and Welfare Benefits Administration at 202-219-8776 (technical assistance) or 800-998-7542

Medicare
Medicare is the national health care insurance program for people 65 and over, certain disabled people, AND people with permanent kidney failure. Medicare will cover the following transplants: heart, heart/lung, lung, Kidney, kidney, simultaneous kidney/pancreas, or a pancreas transplant received after a kidney transplant. Medicare will cover a pancreas transplant alone in some situations. 

Medicare is administered by the Centers for Medicare & Medicaid Services (CMS). There are two parts of Medicare, Parts A and B. In general, Part A covers services you receive while hospitalized. Part B partially covers physician bills, clinic services, home care and other outpatient services. It will also cover 80 percent of the immunosuppressive drug costs as long as you have Medicare, providing you have at least Part A at the time of your kidney transplant and currently carry Part B. If you qualify for Medicare at a later date, due to age or disability, Medicare will cover 80 percent of your immunosuppressive drugs, providing that you at least had Part A at the time of the kidney transplant.

Some states may have Medicare contracts with HMO plans that determine the types of transplant-related services that will be covered. Like all insurance plans, HMO-Medicare plans should be carefully considered since there may be limits on the types of services and medications for which they will pay.

Part A of Medicare is free for most people. There is a monthly premium for Part B. If you receive disability or Social Security benefits, this premium is automatically deducted from your check. Other people are billed quarterly. If you meet financial criteria for assistance through your county welfare department, your state may pay your Medicare premium (called the state buy in program). You may be a Qualified Medicare Beneficiary (QMB), where your county can help you pay the co-payments or deductibles for Medicare if you meet the criteria.

Medigap
Since Medicare may not always cover 100 percent of medical costs, states offer insurance coverage that is a supplement to Medicare to cover such "gaps." This type of plan is called Medigap. You should contact your state insurance commission to determine if you are eligible to purchase a Medigap policy and what type might be best for your situation. Call the National Insurance Consumer Helpline at 800-942-4242.

State High-Risk Insurance
Some states offer insurance coverage to those who have been denied coverage by other health insurance companies because of illness or a pre-existing condition. This is called a high-risk insurance pool. The policy needs to be carefully considered when determining if it will meet your transplant needs. It can be costly and may require a waiting period, which is some times waived on request. This policy can be an excellent resource to cover costs when there are limited insurance options.

Minnesota maintains a high-risk pool, called the Minnesota Comprehensive Health Association, (MCHA) to provide insurance for people who cannot get health insurance or have expensive health conditions. Contact the Minnesota Department of Commerce or the MCHA plan administrator at 651-662-5290 for information about coverage options and premiums.

Medicaid
Medicaid is available to certain low-income people. There are several ways to become eligible, and all should be considered if you feel you may financially qualify. You sh ould also check if the hospital and physicians participate with your state’s Medicaid program.

Supplemental Security Income (SSI)
If you qualify for SSI, you can be eligible for Medicaid. SSI provides a minimum income for people who are age 65 or older, blind, disabled or who have a limited income. Contact the Social Security office at 800-772-1213 to apply.

Categorically Needy
Medicaid can be available for those who are at or below a certain income level (poverty level) designated by their state.

Medically Needy (Spend Down)
You may still be eligible for Medicaid even if your income is above the poverty level in your state. The state may look at the expenses you pay toward medical care and how that affects your monthly income, and then determine what amount qualifies you to become eligible for Medicaid. To find out if you qualify for any of these Medicaid programs, contact the Social Security Office at 800-772-1213. You can also speak to a financial worker at your county department of human or social services. Ask for the name and phone number of the person who assists you in case you need to call them again.

In Minnesota, the Minnesota Department of Human Services administers Medicaid, MinnesotaCare, General Assistance Medical Care (GAMC) and the Prescription Drug Program at 612-296-8517, 800-657-3659, or 800-627-3529 (TTY service).

Veteran’s Benefits
If you are a veteran and have a service-connected disability, you may be eligible to have your medical expenses paid for by the Veteran’s Hospital. The Veteran’s Administration may also cover services and medicines necessary following your transplant. Check with your Veteran’s Hospital or VA office regarding your eligibility and possible benefits.

Paying for costs not covered by insurance
There are some costs that may not be covered by your insurance, and for which you will have to pay. As an example, wages lost when not working, transportation to and from medical appointments, meals, lodging, parking and so on. If your household income is decreased as a result of surgery, it will be important to plan for the time your income is reduced. Although recipients return to work following transplant surgery, it’s helpful to have a plan for how to pay for two to three months of bills or household expenses.

Fundraising
It is not uncommon for family members or friends to provide financial assistance to recipients or donors for non-reimbursed costs. Fundraising can help to cover these costs, and it also allows family, friends or co-workers to be a part of the transplant experience. A family arranged spaghetti dinner or dance, or a call to the local Lion’s or Kiwanis club can help. There are many civic organizations whose mission it is to help people in need. There is no need to feel embarrassed to ask for help, but if you are, have ask someone close to you check into your options.

Paying for transplant medication
Not all insurance policies cover medicines, or may only cover a portion of the costs. It is important to have a plan. Costs can vary from $500 to $2,000 a month, and will typically go down as your dosages decrease over time. Unfortunately, some may try to stretch their medications, reduce or stop taking them altogether because of costs. As a result, they lose their transplanted organ.

Check with your insurance carrier about the following:

• Exactly how much coverage is provided for prescription medicines and medical equipment
• What portion will be your responsibility (such as co-payments or deductibles
• What are the names, phone numbers and locations of pharmacies you can use to get medicines and medical equipment

Check to see whether your policy will pay for medicines at University of Minnesota Medical Center’s Specialty Pharmacy. Their services are specially tailored for the transplant patient. If your insurance company does not cover medicines, you should check into other insurance options and get enrolled.

Patient assistance pharmaceutical programs
Most medicine manufacturers have their own patient assistance drug programs to help cover the cost of the manufacturer’s particular medication. The transplant staff can help you if the companies need information.

National Foundation for Transplant
Formerly known as the Organ Transplant Fund, Inc., this program, based on financial need, may be able to help pay for anti-rejection medicines. Contact them directly to receive an application at 800-489-3863.

Other programs
Your transplant financial case manager or social worker may be aware of other local, state or national programs to assist with anti-rejection medication costs. Notify The Transplant Center immediately if you think there are potential financial problems. It takes time to research assistance programs and process applications.

Appeals
Understanding your insurance coverage is critical. If your insurance denies a service, ask about the process for appealing the decision. Be patient as you move through the steps involved. The transplant staff and doctors can assist you with the appeal, so inform your providers if you are having trouble. We’re here to assist you with any questions or concerns you might have.

Insurance issues checklist
It's a good idea to address these insurance and financial issues before your transplant:

• Determine how your transplant will be paid
• Learn whether new or additional health insurance applications need to be made
• Understand what insurance coverage options and resources are available
• Determine if it is necessary to apply for Medicare and how to do so
• Identify insurance, hospital, employer, county, state and federal resource people
• Research where anti-rejection medicines will be available and covered by insurance
• Learn whether insurance will cover the cost after discharge of required medical equipment
• Determine what out-of-pocket costs you may incur before and after hospitalization and how they will be covered
• Estimate daily living costs for two to three months and make a plan to pay them

Special insurance considerations for kidney transplant
Most people who have a kidney transplant or receive dialysis are eligible to apply for Medicare. Benefits are based on the amount of time you or a spouse (or a divorced spouse) has worked and paid into the Social Security system. Children may be covered by a parent’s work history. Medicare will help pay for a kidney transplant at all Medicare approved facilities. University of Minnesota Medical Center is an approved facility.

Renal Medicare
Kidney transplant recipients are eligible to apply for Renal Medicare at their Social Security office. You may already be eligible if you are age 65 or older; have been receiving Social Security disability for at least two years, or have received dialysis or a previous transplant for your kidney disease. Renal Medicare is distinct from standard Medicare, and you are not eligible to apply for it until you start dialysis or undergo a kidney transplant. At that time, the Social Security Office will determine if you are entitled to these benefits.

Contact the Social Security office at 800-772-1213 or your local Social Security office for a booklet called "Medicare Coverage of Kidney Dialysis and Transplant Services." The booklet addresses specific questions about what Medicare and Renal Medicare will and will not cover for your transplant. You can also call the Medicare Hotline at 800-638-6833 for more detailed information about services covered under Renal Medicare in your region. You can apply by phone or in person.

Renal Medicare eligibility and coverage automatically stops three years after the anniversary month of your kidney transplant, unless you meet other criteria (you are 65 or older, or are disabled or have resumed dialysis). You will be asked to sign a medical evidence report—form 2728 — while you are in the hospital. Once completed, it will be mailed to you to take to your Social Security Office .

State renal programs
About 20 states have state renal (kidney) programs that can help patients with financial costs of a transplant or dialysis. The amount of assistance is typically based on financial criteria, but is designed to help residents with medical costs not covered by other insurance companies. Call the National Organization for State Kidney Programs at 800-733-7345 for information.