Few patients are able to pay all of the transplantation costs from a single source. For example, you may be able to finance the transplant procedure through insurance coverage and pay for other expenses by drawing on savings accounts and other private funds or by selling some of your assets. Most likely, you will have to rely on a combination of funding sources. During your evaluation at California Pacific Medical Center, you will meet with a social worker to discuss financing options and possible sources for obtaining funds. Among the most common funding sources include: private insurance, Medicare and Medi-Cal, CHAMPUS, Veterans Administration Benefits, Social Security Income (SSI)/Social Security Disability Income (SSDI), charitable organizations and fundraising campaigns.
Private insurance often pays for a large portion of kidney and kidney/pancreas transplant costs, however, the terms and extent of coverage vary depending on insurers. Read your policy carefully, including the evidence of coverage (EOC) and contact your insurance provider if you have questions. When speaking with your insurance provider, ask if they will pay for organ recovery charges associated with the operation and medications after transplant. Usually, insurance companies will pay about 80% of your hospital charges. This means you must cover the remaining 20% from other sources.
Most insurance policies have some sort of lifetime maximum amount, or “cap.” After a patient has reached this amount, the insurance company does not have to pay any additional benefits. The amount of cap varies, depending on the individual policy. Sometimes after the transplant, the ongoing cost of care may exceed the cap, so it is important to be familiar with the amount and terms of your insurance cap.
If you have any doubt about how your coverage is determined, contact your insurance company. If you still have questions, contact your State Insurance Commissioner.
Medicare and Medi-Cal
State and/or federal government funding is another possibility for coverage under two programs: Medicare, operated by the federal government; and Medi-Cal, administered by the state with federal assistance.
Medicare is a federally-funded health insurance program available to retirees over age 65, disabled people and other qualifying individuals, such as those with End-Stage Renal Disease (ESRD). There are two parts to Medicare: Part A (hospital insurance) and Part B (medical insurance). Medi-Cal is a state-funded health insurance program for low-income individuals.
The current Medicare deductible for hospitalizations in the year 2012(Medicare Part A) is $1,156, meaning the patient is responsible for this payment. If a patient is hospitalized several times through the year, this deductible must be paid each time, unless the patient is re-hospitalized within 60 days from a previous hospital discharge.
Physician services, or Medicare Part B, are covered at 80% once a $140 annual deductible has been met. The patient is responsible for the 20% of physician fees not covered by Medicare during a kidney or kidney/pancreas transplant hospitalization. These fees are approximately $4,000. Medicare usually reimburses poorly on the anesthesiologist’s bill and there is often a patient responsibility of $400-$500.
Medicare Part D covers prescription medications, excluding the the anti-rejection drugs covered by other parts of Medicare.