Who pays for the transplant?

Financial planning is an important part of the transplant process. Each transplant program includes a financial coordinator to help you understand the cost of transplantation, your insurance transplant benefits, and the overall financial process. You need to know how much your insurance will pay not only for the transplant itself but also for medications after the transplant takes place. You may find it necessary to draw on savings accounts, investments, federal and private assistance options, and fundraising. The financial coordinator and a social worker can answer questions about insurance coverage and assist you in identifying financial resources available to you.

During your evaluation, you will meet with the social worker and the financial coordinator to discuss financial and social issues in detail. Some insurance companies require a review of your evaluation results to determine whether you meet their criteria before they will agree to pay for a transplant. If you are a good candidate for a transplant, the transplant program works with you in obtaining insurance approval from your insurance company. Gaining insurance approval is ultimately the patient’s responsibility, however.

The cost of transplantation and follow-up varies across the United States. You must consider many potential costs—some directly related to your medical care and others that are unrelated to the surgery. Direct medical care costs include pretransplant evaluation and testing; surgery and the postoperative hospital stay; subsequent hospital stays for complications; outpatient follow-up care and testing; antirejection, and other drugs; fees for the hepatologist, surgeon, and anesthesiologist; physical therapy and rehabilitation; and insurance deductibles and copayments. Indirect costs include transportation to and from the transplant center, food and lodging for your family, child care, and lost wages for you and some family members.

Few patients are able to pay for all costs of transplantation from a single income source. Although health insurance companies cover many of the direct costs, savings accounts and other private funds will likely be necessary to pay for other expenses. The transplant social worker and the financial coordinator may be able to suggest alternative sources of funding for those in need, such as charitable organizations, fundraisers, and advocacy groups.

If you have insurance coverage:

• Transplants are very expensive, so you should make sure your healthcare policy does not include any special riders or limitations pertaining to such procedures. 

Prescription coverage is imperative, as the costs of transplant medications are high. If you have a health maintenance organization (HMO) or point of service (POS) insurance plan, make sure you obtain all necessary referrals to avoid any billing issues.

• If your health plan covers only partial costs, your social worker and/or financial coordinator can help you find ways to finance the out-of-pocket expenses. There are programs designed to assist transplant recipients with their unique financial needs.

If you do not have health insurance coverage:

• Not having health insurance poses a challenge for patients in need of transplants, but your financial coordinator can help you investigate other options, such as state or federal funding or insurance and assistance through charitable organizations or advocacy groups.

• Check with your local Medicaid office to see whether you are eligible for this coverage, which is based primarily on income. In addition, most states operate a high-risk health insurance pool for individuals with preexisting conditions who need to purchase an insurance plan. Check with your state’s insurance commissioner for more information.

• On the Internet, you can log on to your state’s website to find links to government agencies dealing with insurance or health care. You can also consult your local phone book for agency listings under the government section.

• Several agencies will assist you in fundraising, and the social worker and financial coordinator can provide you with information on these resources. If you are out of work due to disability, you should apply for Social Security Disability Insurance. You will become eligible for Medicare coverage after receiving these Social Security benefits for 2 years. For more information, consult the websites for Medicare or the Centers for Medicare and Medicaid Services.