Does Medicare Cover Bone Marrow Transplants?
- Does Medicare cover bone marrow transplants? Find out the answer, including information about what a bone marrow transplant is and who is eligible for Medicare coverage.
A bone marrow transplant is a procedure that's sometimes used to treat certain cancers, aplastic anemia and immune system disorders. The therapy can help treat the underlying condition and make it easier for the body to cope with other treatments, such as chemotherapy.
If you've been told you need a bone marrow transplant, you may be wondering whether your Medicare policy can help you manage the costs involved.
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Does Medicare Cover Bone Marrow Transplants?
Medicare Part A may cover bone marrow transplants if the procedure is considered medically necessary. However, it only covers bone marrow transplants for certain health conditions where there is a strong body of evidence to support the treatment's efficacy.
Medicare will usually consider paying for bone marrow transplants for the following conditions:
- Leukemia, including for people in remission who are at a high risk of relapse
- Aplastic anemia
- Wiskott-Aldrich syndrome
- Severe combined immunodeficiency disease (SCID)
- Non-Hodgkin's lymphoma
- Neuroblastoma
- Severe Hodgkin's disease that hasn't improved with conventional treatment
Furthermore, Medicare may cover bone marrow transplants for people with myelodysplastic syndromes (MDS) if they are participating in a CMS-approved clinical study designed to test the efficacy of the therapy for treating MDS. It does not usually cover bone marrow transplants to treat solid tumors unless they are neuroblastomas.
Even if you have one of the conditions generally accepted for Medicare coverage, whether you are ultimately approved for coverage for your bone marrow transplant may depend on your overall health.
For example, you may only be eligible if you have sufficient cardiac function to cope with the demands of the treatment. If you have a condition not included in the list of conditions covered for bone marrow transplant under Medicare but your doctor thinks it's an appropriate treatment, your local Medicare Administrative Contractor will decide if you are eligible.
When Medicare covers a bone marrow transplant, it covers costs associated with harvesting the stem cells, transplanting them into the recipient, and any chemotherapy or radiotherapy necessary to prepare for the transplant.
However, Part A and B don't usually pay for the various medications involved in a bone marrow transplant. They may be covered under Medicare Part D if you have it, or a Medicare Advantage (Part C) plan that includes Part D prescription drug coverage.
Generally, Medicare only pays for 80% of the costs associated with your treatment. You are liable for paying deductibles and coinsurance, and the costs can add up significantly.
Medigap – or Medicare Supplement Insurance – is a type of secondary insurance that pays some of the deductibles and coinsurance after Medicare has paid for its portion of the treatment costs.
Does Medicaid Pay for Bone Marrow Transplants?
Medicaid will generally pay for bone marrow transplants to treat certain diseases.
To qualify for funding, the treatment must be medically necessary. The beneficiary's health care team must also be satisfied that there is no more conservative or less expensive way to treat their disease or symptoms successfully.
Whether you will be required to pay deductibles or coinsurance depends on your state's policies, and you may be exempt from sharing the costs of treatment if you are a minor or clinically vulnerable. If you have dual eligibility for Medicare and Medicaid, your coverage will likely pay for most of your medical costs, including any medication.
How Can I Get a Bone Marrow Transplant Without Insurance?
People without health care insurance may be able to get coverage through a government-sponsored scheme.
If you're ineligible, you may still be able to get a free bone marrow transplant if you're willing to participate in a research trial through the National Cancer Institute's Center for Cancer Research or National Heart, Lung and Blood Institute.
What Is a Bone Marrow Transplant?
A bone marrow transplant involves introducing filtered, healthy stem cells into the bloodstream, and the cells can come from the person being treated or a donor. Stem cells can create new, identical cells or varieties of similar cells, making them a useful part of many treatment protocols.
Introducing healthy stem cells via a bone marrow transplant can help increase immunity, replace diseased bone marrow or bone marrow that's been damaged by other treatments and help reduce the damage caused by certain genetic diseases.
Which type of bone marrow transplant you receive depends on various factors, including your health status and who will donate the received bone marrow. Below are some of the most common types.
Autologous Transplant
This treatment is sometimes referred to as an autologous bone marrow rescue. During treatment, your own stem cells are taken from the bone marrow or collected from the bloodstream. They are then reintroduced once other treatments are finished to help you recover and replace damaged bone marrow.
Allogeneic Transplant
Allogeneic bone marrow transplants involve transplanting healthy stem cells from a donor who is a close genetic match to the recipient. The stem cells can be harvested from the donor's bone marrow or bloodstream.
The most common donor choice for an allogeneic bone marrow transplant is a sibling because they are the closest genetic relation to the recipient. If there is no sibling donor available, a parent may be able to donate bone marrow to their offspring. Occasionally, an unrelated donor can be found through a bone marrow registry if there is no suitable donor in the family.
Syngeneic Transplant
Syngeneic bone marrow transplants involve transplanting stem cells taken from the bone marrow of the recipient's healthy identical twin. This type of bone marrow transplant is more unusual due to the relative rarity of identical twins.
Umbilical Cord Blood Transplant
The blood inside a baby's umbilical cord is a rich source of stem cells immediately after birth, and they generate new cells more efficiently than stem cells harvested from bone marrow. Some parents choose to donate their babies' umbilical cord blood, and the cells can be frozen and donated to a recipient when required.
Although stem cells are often removed from the bone marrow of a healthy recipient, they aren't transplanted directly into the recipient's own bone marrow. Instead, they are introduced into the bloodstream, making their way to the bone marrow and generating new cells. Most people will undergo intensive chemotherapy or radiotherapy before a bone marrow transplant to create space within the bones for new marrow and treat their underlying condition.
