Does Medicare Cover Heart Transplants?
Original Medicare (Part A and Part B) does cover heart transplants and certain other organ transplants if considered medically necessary by a doctor.
Medicare Advantage (Part C) plans also cover heart transplants, and they also include an annual out-of-pocket spending limit. This can potentially save you money in Medicare costs for your heat transplant.
Original Medicare does not include an out-of-pocket spending cap.
How much does Medicare pay for heart transplants?
Hospital costs related to your heart transplant are typically covered by Medicare Part A.
Doctor services related to your transplant are typically covered by Medicare Part B.
Even if Medicare covers your heart transplant, you are generally responsible for a portion of the costs. Some of these costs include:
- Medicare Part A deductible:
The Part A deductible is $1,364 per benefit period in 2019.
A benefit period begins the day you are admitted to the hospital and ends when you’ve been discharged for at least 60 days. If you’ve been out of the hospital for more than 60 days and are admitted again, a new benefit period begins.
You must pay your Part A deductible before Medicare will pay its share for covered hospital services. - Medicare Part A coinsurance:
After you meet your Part A deductible, you are typically responsible for paying Part A coinsurance costs.- Days 1-60 spent in the hospital: $0 coinsurance for each benefit period
- Days 61-90: $341 coinsurance per day of each benefit period
- Days 91 and beyond: $682 coinsurance per each “lifetime reserve day” after day 90 for each benefit period
- Beyond lifetime reserve days: you are responsible for all costs
Lifetime reserve days are 60 additional days of coverage that can be used over the course of your life. For each lifetime reserve day, Medicare pays all covered costs except for the daily coinsurance. Once you use these 60 days, they cannot be renewed.
- Medicare Part B deductible:
The Part B deductible is $185 per year in 2019.
You must pay your Part B deductible before Medicare will pay its share for covered doctor services. Once your Part B deductible is met, Medicare typically pays 80 percent of the Medicare-approved amount for covered doctor services, and you pay 20 percent.
If you have a Medicare Advantage plan, your coinsurance and deductible costs could vary. Some Medicare Advantage plans may include $0 deductibles. All Medicare Advantage plans include an annual out-of-pocket spending limit.
Depending on the type of Medicare Advantage plan you have, you may be required to get your heart transplant from a doctor or hospital in your plan network.
For specific pricing information regarding your heart transplant, we recommend speaking with your doctor directly.
Does Medicare cover transplant drugs?
Medicare covers immunosuppressive transplant drugs if Medicare also helped pay for your heart transplant.
- You will typically pay 20 percent of the Medicare-approved amount for prescription drugs that Part B covers (after you meet your Part B deductible).
- If Medicare Part B doesn’t cover your transplant drugs, you could pay 100 percent of the costs for the drugs, unless you have a Medicare Part D plan or a Medicare Advantage plan that includes prescription drug coverage.
Medicare Advantage plans also cover heart transplants
Medicare Advantage (Medicare Part C) plans are sold by private insurers as an alternative to Original Medicare.
Every Medicare Advantage plan must provide the same hospital and medical benefits as Medicare Part A and Part B, which means if your heart transplant is covered by Original Medicare, it should also be covered by Medicare Advantage.
In addition to the basic benefits every Medicare Advantage plan must provide, many Medicare Advantage plans offer additional benefits that aren’t offered by Original Medicare.
Examples of some of these additional benefits include:
- Prescription drug coverage
- Dental coverage
- Vision coverage
- Hearing coverage
- Health and wellness program benefits, such as SilverSneakers membership
To learn more about Medicare Advantage, or to find Medicare Advantage plans in your area, speak with a licensed insurance agent.
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