Financial Matters
When considering a kidney or kidney/pancreas transplant, the associated costs and how you can best handle them must also be considered. At California Pacific Medical Center, a financial coordinator meets with patients during their initial evaluation to review specific insurance coverage issues related to transplantation.
The following material briefly outlines transplantation costs and financial options. For further information, contact Isabel Zamora, transplant admissions coordinator at California Pacific Medical Center. You may also find out newsletter article helpful, Financial Preparations for Kidney Transplant.
Transplantation Costs
The costs of your transplant include transplant evaluation and testing, transplant surgery and follow-up care and medication.
Even before a transplant, you have probably received many medical bills for treatment by your physician, hospital, laboratories and medical specialists. These costs add up quickly.
One of the biggest costs--and one that varies greatly according to a patient's condition--is time spent in the intensive care unit (ICU). Patients are generally taken to the ICU after the transplant operation and some patients are treated in the ICU before the transplant, depending on their condition.
Other costs associated with transplantation include:
- recovery and in-hospital stay
- extensive lab tests
- anesthesia
- fees for transplant surgeons and operating room personnel
- organ recovery
- lodging and food for family members while the patient is hospitalized
- physical therapy and rehabilitation
- anti-rejection drugs and other medications (these costs can easily exceed $10,000 in the first year, and these medications are required for the rest of a transplant recipient's life).
According to the United Network for Organ Sharing (UNOS), estimated charges for transplantation are:
Kidney
Estimated First-Year Charge: $116,100
Estimated Annual Follow-up Charge: $15,900
Pancreas
Estimated First-Year Charge: $125,800
Estimated Annual Follow-up Charge: $6,900
Following your transplant, you will need several drugs, called immunosuppresives, to sustain your transplanted kidney and/or pancreas. The immunosuppressive medications may include Cellcept, Prograf and Prednisone. The following are estimates and depend on the dosage and pharmacy used. Note that most health plans pay a percentage of medication costs, as described in the next section.
- Cellcept: Total monthly cost is approximately $815
- Prograf: Total monthly cost is approximately $1,087
- Prednisone: Total monthly cost is approximately $13
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Financing Transplantation
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, you will meet with a transplant coordinator 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.
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Private Insurance
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.
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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 2002 (Medicare Part A) is $812, 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 $100 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.
For more information on Medicare, see www.medicare.gov. For Medi-Cal information, visit www.medi-cal.ca.gov.
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CHAMPUS
Government funding for families of active duty, retired or deceased military personnel may be available through the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). CHAMPUS shares the cost of kidney and kidney/pancreas transplants for patients with end-stage organ disease. Patients must receive pre-autorization from the CHAMPUS medical director and meet program criteria.
For more information, contact the health benefits advisor at your nearest military healthcare facility.
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Veteran's Administration (VA)
If you are a veteran, the VA can help pay for treatment. Contact your local VA office for more information.
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Social Security Income (SSI) and Social Security Disability Income (SSDI)
These benefits are available from the Social Security Administration. They assist you with the costs of daily living. To find out if you qualify, talk to your social worker or call your local Social Security office.
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Charitable Organizations
Charitable organizations offer different types of support, ranging from disease and transplant information to limited financial assistance through grants and direct funding. Usually, you must apply for the funding. However, it is very unlikely that one group can cover all of the costs for an individual patient. If you are interested in pursuing funds from a charitable organization, a social worker at California Pacific can provide counseling on your options and how to apply.
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Fundraising Campaigns
Patients and families often use public fund raising to help cover expenses not paid by medical insurance, such as child care, transportation, food and lodging. This may, in fact, be a key source for financing transplantation. Proceed with caution and plan carefully before you begin, because there are many legal and financial issues to consider. For example, if you and your family have been accepted for Medicaid benefits and funds are raised for you, the donated money could be counted as income, and you may then lose your eligibility.
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Self-Pay
Occasionally, patients may prefer to pay out-of-pocket for all transplantation costs. This is particularly true for patients from overseas without health insurance (who are permitted by United Network for Organ Sharing (UNOS) regulations to account for a small fraction of a transplant program's patients). The financial coordinator will review estimated rates for evaluation and transplantation and a discount will be given on the total bill at the time of discharge. For more information, contact Isabel Zamora.
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Resources
The following organizations may provide financial assistance to qualified transplant candidates or recipients and their families.
American Kidney Fund
1-800-638-8299
American Organ Transplant Association
(281) 261-2682
National Transplant Assistance Fund
1-800-642-8399
National Foundation for Transplants, Inc.
1-800-489-3863
Medicare Hotline
1-800-633-4227
1-800-MEDICARE
* This information was adapted from "Financing Transplantation: What Every Patient Needs to Know." United Network for Organ Sharing: UNOS. copyright 1994.
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