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A kidney transplant is a surgical procedure that involves replacing an individual’s kidney when it no longer functions correctly. It is replaced with a kidney from a healthy donor.
People with end-stage renal disease must undergo either dialysis or a kidney transplant to survive.
If you or a loved one are facing a situation like this, a common question is, “Does Medicare cover Kidney Transplants?”
In this article, we answer the question in clear, plain English. You will also find the average kidney transplant cost for those who have to pay out of pocket.
Does Medicare Cover Kidney Transplants?
The short answer is yes; Medicare will cover the cost of a kidney transplant. But this is not the case 100% of the time.
As usual with Medicare, certain conditions have to be met for them to pay for your kidney transplant. Below we look at what these are so you know what to expect.
Original Medicare Coverage of Kidney Transplants
Original Medicare (Medicare Part A and Part B) provides coverage for kidney transplants. It will also provide coverage for your dialysis at home if considered medically necessary.
Your healthcare provider must first order the operation for Original Medicare to provide coverage.
When is Coverage Provided by Part A?
Coverage for kidney transplants is provided by Medicare Part A if your kidney transplant is for the parts of the surgery that take place in an inpatient setting.
Typically, Part A covers the following for kidney transplants:
- Inpatient stay
- Kidney registry fee
- Laboratory and other screenings to evaluate your medical condition, as well as the condition of potential kidney donors
- The costs of finding the proper kidney for your transplant surgery if there is no kidney donor
- Any additional inpatient hospital care for your donor in case of problems from surgery
- Blood (whole units of packed red blood cells, blood components, and the cost of processing and giving you blood)
- Inpatient care you needed before surgery
Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days.
Starting from the 61st day up to 90 days, Medicare Part A will still provide coverage. However, you will pay a daily copayment during that time. After 90 days, Medicare Part A will no longer provide coverage.
Though Medicare Part A provides 60 lifetime reserve days. If you have them, they will still provide coverage for your hospital stay after 90 days, but you will have a daily copay.
When is Coverage Provided by Part B?
Coverage for things related kidney transplants is provided by Medicare Part B when they take place in an outpatient setting.
Part B provides coverage for the following kidney transplants:
- Doctors’ services for kidney transplant surgery which includes care before, during, and after surgery
- Doctors’ services for your kidney donor during their hospital stay
- Immunosuppressive drugs
Once approved, Medicare Part B covers 80 percent of the costs of kidney transplants. You will pay for the remaining 20 percent.
Medicare Advantage Coverage of Kidney Transplants
Medicare Advantage plans (Medicare Part C) also provide coverage for kidney transplants. These plans must cover the same things Original Medicare covers.
But they offer some additional benefits as well. Exactly what a plan covers and how much the out-of-pocket costs will be varies on a plan-by-plan basis.
If you only have Medicare coverage because of End-Stage Renal Disease, your Medicare coverage will end 36 months after your successful kidney transplant, including immunosuppressive drug coverage.
Original Medicare also provides coverage for dialysis at home. Original Medicare provides coverage for your dialysis at home if considered medically necessary. Your healthcare provider must first order the operation for Original Medicare to provide coverage.
How Much Do Kidney Transplants Cost?
The average cost of a kidney transplant is $260,000 or more in total. This includes pre-transplant screening, donor matching, surgery, post-surgical care and the first six months of drugs.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always be sure to double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series, including: Does Medicare Cover IVIG Treatments?