For people who have end-stage heart failure or severe coronary artery disease, having a heart transplant might be necessary if other treatments haven’t helped. Also known as a cardiac transplant, a heart transplant is a complicated procedure that involves removing a functioning heart from a deceased organ donor on life support and implanting it in the patient. In some cases, the heart and both lungs are transplanted together.
Every year, over 1750 heart transplant procedures are performed in the United States as a life-saving treatment for recipients of all ages. In fact, one out of every 50 people who have heart transplants is over the age of 70.
Heart failure, the leading reason for undergoing a heart transplant, is a condition that results from a dysfunctional heart that can’t pump enough blood to oxygenate the body. The occurrence of heart failure is more common in the elderly and is the leading cause of hospitalization for people who are older than 65, which makes many of them candidates for heart transplants.
Today, decades of medical research have proven that receiving a heart transplant can extend a person’s life substantially, no matter how old they are.
How does Medicare insurance cover organ transplants?
If you are enrolled in either Original Medicare Parts A and B or a Medicare Advantage (Part C) plan, you have coverage for medically necessary health care services that are preventive, diagnostic, or for the treatment of a health matter. If your physician certifies that you need an organ transplant, your Medicare insurance covers it if you meet the eligibility requirements set by an organ transplant program in your service area.
Besides heart transplants, Medicare also covers the following organ transplants when they are handled by Medicare-affiliated transplant programs that operate out of hospitals that accept Medicare assignment:
Medicare also covers cornea and stem cell transplants, but they don’t need to be done in hospitals that accept Medicare assignment.
Original Medicare coverage for a heart transplant
If you are enrolled in Original Medicare, your heart (or another organ) transplant is covered by both Parts and B. Medicare Part A (inpatient hospital insurance) covers the following services necessary for your heart transplant:
- Procurement of the organ
- Transplant surgery
- Medically necessary tests, lab tests, and other examinations
- Medical services for heart, lung, kidney, pancreas, intestine, and liver transplants
- Stem cell transplants
- Immunosuppressive drugs
- Follow-up care
Original Medicare Part A pays for the medical services listed above after you have paid your Part A deductible for the current benefit period. A benefit period begins on the first day of your admission as an inpatient, and it ends when you’ve been out of the hospital for 60 consecutive days. You may also be responsible for paying coinsurance fees if you’re an inpatient for more than 60 days, or in a skilled nursing care facility for more than 20 days.
Medicare Part B (outpatient medical insurance) covers the following services regarding your transplant:
- Physicians’ services necessary for your organ transplant
- Bone marrow transplants
- Cornea transplants
- Immunosuppressive drugs that you take outside of inpatient hospital care
For benefits covered by Original Medicare Part B, you pay 20 percent of the final approved amount for physicians’ services after paying your annual Part B deductible. Depending on your care, you may also be responsible for paying certain charges to the transplant facility that is managing your organ transplant.
How Medicare Advantage (MA) plans may cover transplant coverage
If you have coverage through a Medicare Advantage (Part C) plan, your provider must cover medically necessary services that would otherwise be covered by Original Medicare Parts A and B. However, your MA plan may have different requirements regarding which medical facilities, hospitals, physicians, and medical suppliers you can use. You should discuss all the details of your coverage with your provider before making health care decisions.