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Does Medicare Cover Lung Transplants?

Yes, Original Medicare does cover lung transplants, given that a doctor verifies replacement surgery as medically necessary to save a person’s life. 

Part A typically pays for hospital expenses at Medicare-approved facilities, including lab testing, procurement of organs, and lung transplant surgery. Meanwhile, Part B will cover any associated doctor’s services. Part B will also cover the cost of immunosuppressive drugs during recovery if Medicare paid for the transplant. 

When Is a Lung Transplant Necessary? 

If you have critically diseased or damaged lungs that have not responded to alternative treatments, you will likely require a transplant. This surgery involves the replacement of one or both lungs with healthy organs procured from a deceased donor. Conditions that typically necessitate lung transplant surgery include the following:

  • Cystic fibrosis
  • Chronic obstructive pulmonary disease
  • Severe bronchiectasis

Organ donations and replacements save lives and require extensive care before, during, and after operations, which can quickly become prohibitively expensive. Therefore, Medicare beneficiaries should understand how lung transplant surgery would align with their coverage to ensure quality care for a minimal out-of-pocket contribution.

Understanding Medicare Coverage for Lung Transplants 

Medicare will cover lung transplants for patients with injuries or illnesses requiring medically necessary organ replacement surgery. Typically, this diagnosis occurs after doctors and specialists have tried and failed to utilize other forms of treatment. For Medicare to cover a medically necessary transplant, the operation must occur in a Medicare-approved hospital with a transplant program.

All organ transplants require extensive pre-surgery and post-surgery care. Depending on the nature of your operation, Medicare Part A, Part B, and Medigap can all help pay for varying aspects of care, including the actual surgery, hospital stays, tests, medications, and various out-of-pocket expenses.

Medicare Part A Coverage 

Medicare Part A (Hospital Insurance) generally covers most of the costs associated with inpatient stays in a hospital, skilled nursing facility, or eligible hospice and home healthcare environment. These expenses typically include on-site procedures, equipment, supplies, tests, and anything else required to provide residents with quality care.

Regarding organ transplants, Part A will help pay for any on-location exams, labs, and tests needed before, during, or after the surgery. Part A will also cover the procurement of organs, the actual lung transplant cost, stem cell transplants, and any immunosuppressant drugs and follow-up care needed during recovery.

Medicare Part B Coverage 

Medicare Part B (Medical Insurance) typically covers outpatient doctor’s care, medical supplies, durable medical equipment, and preventative tests and services. While most people automatically receive Part A upon turning 65, Part B is an optional coverage that primarily pays for treatments verified as medically necessary by a doctor.

Part B will cover any doctor’s services required before, during, or after a qualified organ transplant, including ongoing diagnosis, routine checkups, and adjustment of care plans. Part B may also cover immunosuppressive drugs for individuals who had Part A at the time of the surgery and Part B at the time of the prescription.

Medigap Coverage 

Several private health insurance companies sell various Medigap plans to help fill “gaps” in Original Medicare benefits. Though coverage varies depending on your specific policy, Medigap helps absorb deductibles, coinsurance, copayments, and other healthcare expenses patients typically must pay for out-of-pocket.

How Does Medicare Advantage Cover Lung Transplants? 

Medicare Advantage, sometimes called Medicare Part C, must legally cover all the same services as Original Medicare. However, the private companies that fund and structure these policies often include additional benefits like dental care, gym memberships, or prescription allowances for little to no extra cost.

Unlike Original Medicare, which allows members nationwide access to most healthcare facilities, Medicare Advantage companies sell HMO, PPO, PFFS, and POS plans with independent medical networks and rules surrounding outside care. Medicare Advantage companies can also impose preauthorization and other unique coverage barriers. 

Therefore, if you need a lung transplant covered under Medicare Advantage, call your insurance company to ensure your doctors, specialists, and hospital fall within your network and that the operation meets your policy’s guidelines.

How Much Does a Lung Transplant Cost With Medicare? 

A lung transplant can cost anywhere from $200,000 to $1,000,000 without insurance, depending on the following factors:

  • Surgical complexity
  • Potential complications
  • Time spent hospitalized
  • Required drugs
  • Recovery duration

Considering the prohibitive nature of such an involved and expensive procedure, Medicare Part A, Part B, and Medicare Advantage all play essential roles in giving beneficiaries of average means access to quality care.

Medicare Part A Costs 

Most seniors automatically receive premium-free Part A by paying at least 10 years of Social Security taxes. After a patient covers their annual $1,632 deductible, Part A will pay 100% of various transplant facility charges, procurement of organs, and certified lab tests. However, beneficiaries who remain in the hospital beyond 60 consecutive days must begin paying a $408 coinsurance that can increase over time.

Medicare Part B Costs 

Medicare-eligible seniors must purchase Part B for a monthly $174.70 premiumAfter beneficiaries meet their annual $240 deductible, Part B will pay 80% of the Medicare-approved amount for outpatient doctor’s service associated with a lung transplant. Likewise, Part B will occasionally cover 80% of necessary immunosuppressant drugs or durable medical equipment like crutches and oxygen tanks required during recovery.

Medicare Advantage Costs 

While Medicare Advantage must legally cover all the same services as Original Medicare, the private companies overseeing these policies can set independent cost-sharing protocols and barriers to coverage. If you have Medicare Advantage and require a lung transplant, contact your insurance carrier in advance to verify your eligibility for surgery and receive an estimate for your share of associated expenses.

Does Medicare Cover Lung Cancer Screenings? 

Yes, Medicare Part B will cover 100% of one annual low-dose computed tomography lung cancer screening for people who meet all the following conditions:

  • They fall between the ages of 50-77
  • They have no existing signs or symptoms of lung cancer
  • They actively smoke cigarettes or quit within the past 15 years
  • They have a smoking history of at least 20 “pack” years (an average of 20 cigarettes a day for 20 years)
  • They received an order from their doctor

To guarantee coverage, the specialists and facility providing the screening must accept Medicare assignment. Notably, Medicare Advantage Plans must also cover 100% of lung cancer screenings for beneficiaries who meet the above criteria and receive their tests from in-network providers.

All in All 

Lung transplants are intensive surgeries that require concentrated medical attention before, during, and after each procedure. Consequently, costs associated with a successful operation can reach upwards of $1 million. 

If you have Original Medicare and meet the eligibility criteria for surgery, you would pay considerably less for a lung transplant than you would without insurance. Call 1-800-MEDICARE or contact your specific Medicare Advantage provider to verify your coverage and expected out-of-pocket contributions.

Frequently Asked Questions

While eligible beneficiaries can choose between lung transplant centers, the hospital that performs the operation must accept Medicare assignment and fall in line with Medicare standards of care. Medicare criteria for an approved health center include high survival rates, Organ Procurement and Transplant Network (OPTN) membership, and convenient access to laboratory services.

Before December 2022, a transplant patient could lose coverage for immunosuppressive drugs 36 months after their operation. Today, eligible seniors and people with disabilities can enroll in Medicare Part B-ID, which covers all FDA-approved transplant medications. After covering their monthly premium and deductible, Part B-ID would indefinitely pay for 80% of a transplant recipient’s follow-up pharmaceutical regimen.

Medicare Part A will fully cover up to 60 days of recovery services provided at a beneficiary’s primary hospital or an inpatient rehabilitation facility. After paying a $408 daily coinsurance for days 61-90, these individuals will owe $816 for every additional “lifetime reserve day,” which permanently expire after use. After 150 days of inpatient rehabilitation, patients must pay for 100% of continued care out-of-pocket.

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