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Financial Issues

Transplant Services has access to the Baylor University Medical Center's experienced financial services team who educates and assists transplant patients with their financial needs and insurance coordination. This team provides information on insurance benefits, Medicare, Medicaid, fundraising and other financial areas that may apply.

Transplant Financing

Insurance, Medicare, Medicaid, Fundraising

The following information is intended to help you understand the financial aspects of organ transplantation.Transplantation requires the use of many hospital resources and supplies; therefore, it is necessary to prepare in advance for payment of patient charges. Most patient charges are paid by insurance companies, Medicare or Medicaid. Please read your insurance policy, Medicare or Medicaid handbooks so that you understand your coverage and are aware of any out~of~pocket expenses you will be expected to pay.

Baylor University Medical Center is available to assist you in understanding your insurance benefits and how they apply to transplantation. Please contact the Baylor Transplant Patient Access Services Department at (214) 820-3476 between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday, to discuss your particular situation.

Private Insurance

If you have private insurance, it will be important to understand your insurance policy provisions and coverages. Below is a list of questions you may want to ask your insurance company in regard to transplant coverage. Don't hesitate to ask your insurance representatives questions. They are there to help you understand your coverage and its limitations.

Questions to Ask Your Insurance Company:

  • Is transplantation a "covered service" under my policy? If so, are there any exclusions or dollar amount limits? If there is a dollar amount limit, how much?
  • Is organ procurement covered under my policy? If so, are there any dollar amount limits? If there is a dollar limit, how much?
  • Is pre~authorization required for a transplant or for any pre~ transplant treatment? Do I need to supply any information? Do you select "centers of excellence" for the type of transplant I need? If so, must I go to one on your list?
  • Does the plan cover the cost of travel and lodging for me to go to these centers if they are not nearby? Would my family's travel and lodging also be covered? What about travel for follow~up care?
  • Is there a waiting period for coverage? If so, how long is it? Am I currently in the waiting period?
  • Are there any permanent exclusions to my policy? If so, what are they?
  • Is a second opinion required?
  • What percentage of costs are paid by my policy? Does it vary by the type of service provided (i.e. surgery, test, prescriptions)?
  • Are there any deductibles or co-payments? What are my total maximum "out-of-pocket" expenses per year?
  • Are there separate deductibles or co-payments for prescriptions, physician/professional services or surgery? If so, what are they?
  • Do you have a maximum amount of "cap" on my coverage? Can this limit be exceeded?
  • Will you pay for my immunosuppressive medications after the transplant?
  • Is there any time limit on coverage for my medications? Are prescription medications included in the maximum? If not, what is the prescription maximum?
  • Whom should I call for questions or problems with my coverage?

COBRA

Consolidated Omnibus Budget Reconciliation Act

If you have ended full-time employment recently, you may be eligible for COBRA coverage. Employees who enroll in Medicare may not be eligible. In this case, the employer is not required to offer COBRA coverage, but the employer may choose to offer COBRA coverage. Under COBRA, an employer with 20 or more employees must offer continuation of the group health plan (for an 18 to 29 month duration) to an employee whose employment has ended. Certain eligibility standards must be met and the employee is responsible for payment of premiums at the same cost (plus 2%) that the employer was paying. A dependent of the employee may be eligible for 36 months of coverage. To determine your eligibility for COBRA coverage, contact your employer's employee benefits office. In addition, you may contact:

Pension and Welfare Benefits Administration (for non-government employees)
(866) 275-7922

Medicare

Medicare is a health insurance program for persons age 65 and older, some individuals with disabilities who are under age 65 and those with end-stage renal disease or "ESRD" (permanent kidney failure treated with dialysis or a transplant). Visit www.medicare.org for specific information about eligibility requirements or contact the Medicare hotline at (800) MEDICARE.

Medicare has two parts: A and B. 
Medicare Part A (hospital insurance) usually requires no premium payment and typically covers evaluation and inpatient services for kidney, pancreas, liver, heart, heart/lung and lung transplants in an approved facility. Blood and marrow transplants are covered only under specific diagnoses. Medicare Part B (additional medical insurance) requires a monthly premium and typically pays for post-transplant outpatient services and immunosuppressive drugs for a period of time, beginning with the discharge date of the transplant hospital stay. On August 6, 1993, Congress passed the Consolidated Omnibus Budget Reconciliation Act of 1993, which has extended Medicare coverage to 36 consecutive months on immunosuppressant medications for those who met the eligibility guidelines and were discharged following transplant on or after July 1, 1995.

Medicare Supplemental Insurance (Medigap Policy)
Medicare Part B does not always cover 100% of all medical costs. Medicare supplemental policies (Medigap) are intended to cover the cost of some of the services that Medicare does not. In every state, there are standardized Medigap policies created to fill these "gaps" in coverage.

Generally, an individual must purchase one of these Medigap policies within six months of their Medicare effective date.

There are only three Medigap plans (H, I, and J ), which offer LIMITED coverage for outpatient medications.

You are strongly encouraged to call your state's insurance department to determine if you are eligible to purchase one of these policies. They can also advise which insurance companies are selling Medigap plans H, I, or J. For the number of your state's insurance department, call the National Insurance Consumer Helpline at (800) 942-4242.

Medicare HMO Plans
In a number of states, including Texas, it may be possible to obtain Medicare coverage through a health maintenance organization (HMO). Some Medicare HMOs are providing coverage for immunosuppressants with no deductible and no co-payment for the period of time that Medicare would cover immunosuppressants. In addition, there also may be a limited prescription medication benefit available. Individuals with ESRD may not be eligible for this coverage.

Caution: If you decide to switch to a Medicare HMO, you may not be able to return to your previous Medigap (Medicare supplemental- Plan H, I, J) policy if you return to standard Medicare. Please check on this.

For further information on availability in your state, call the Medicare hotline at (800) MEDICARE (633-4227) or for your state's insurance department, call the National Insurance Consumer Helpline at (800) 942-4242.

Medicaid Coverages
Medicaid is a jointly funded cooperative venture between federal and state governments to assist states in the provision of adequate medical care to eligible needy persons with low incomes and resources, children, the aged, blind and/or disabled. Each state has its own eligibility guidelines; however, in general, there are two classifications of need under the Medicaid program:

1. Categorically Needy - Individuals at or below the state income level designated as the "poverty line" by the federal government may be covered by Medicaid for health care, assuming all eligibility criteria are met.

2. Medically Needy (Spend Down) - In some states, including Texas, individuals who are above the income and resource level designated as the "poverty line" may be eligible for Medicaid through the medically needy program. In the states where such a program is offered, individuals are allowed to "spend down" their excess income (but not resources) to the "poverty line" over a period of time. The "spend down" is similar to a "deductible." It is the process of using medical expenses to reduce the income of an individual to the level of eligibility for Medicaid.

Supplemental Security Income (SSI)
SSI provides a minimum income level for the aged (age 65 and older), blind, individuals with disabilities, and couples with limited income and resources.

For more information regarding Medicaid, Spend Down and SSI, call the Social Security Office at (800) 772-1213.

High-Risk Insurance Pools
High-risk insurance pools serve individuals who have pre-existing health conditions, and often are denied, or have difficulty finding affordable coverage in the private insurance market. These policies may be rather expensive or unavailable in your state and should be considered carefully to determine if they meet your needs. However, when available, they may be an excellent way to obtain necessary health coverage. A state-by-state directory of high-risk insurance policies compiled by an organization called Communicating for Agriculture and the Self-Employed may be ordered by calling (800) 432-3276. For information on the Texas high-risk pool, call (888) 398-3927.

Fundraising
The following organizations vary in their approach toward fundraising, but their end goal is the same: to help those waiting for a transplant. Contact these organizations directly for more information.

National Foundation for Transplants
1102 Brookfield, Ste. 200
Memphis, TN 38119
(800) 489-3863

www.transplants.org

National Transplant Assistance Fund
3476 West Chester Pike, Ste. 230
Newton Square, PA 19073
(800) 642-8399
www.transplantfund.org

Baylor Contact Information
Transplant Patient Access Services Department
3410 Worth St., Suite 950
Dallas, TX 
Phone: (214) 820-3476
Fax: (214) 820-1510

Notice re Financial Issues Information
This web page contains general information regarding transplant financing and is provided solely as a convenience to our patients and their families. It is not intended to be specific legal, financial or other professional advice and should not be relied upon as such.

The telephone numbers and websites referenced are operated and maintained by third parties and are provided solely as a convenience to our patients and their families. Baylor Health Care System does not maintain, operate or endorse the telephone numbers or the websites, their operators or their content.