Does Medicare Cover Lung Transplants?

In this article...
  • Does Medicare cover lung transplants? Discover everything you need to know about eligibility and how much Medicare pays for lung transplant surgery and care.

Lung transplants involve replacing a diseased or damaged lung with a healthy donor organ. You may need one or both of your lungs replaced if you have a serious pulmonary condition. 

A lung transplant is a major surgery, and you will need significant medical support before and after the procedure. It's also very expensive, so it's important to have health care insurance in place. So, does Medicare cover lung transplants? Below, you can find out about Medicare lung transplant eligibility. 

Does Medicare Cover Lung Transplants?

Medicare may cover some of the costs of a lung transplant if the procedure is medically necessary. Medicare Part A and B pay for the medical tests associated with lung transplants for eligible beneficiaries. It also covers the costs of the procedure and doctors' fees, provided the surgery is performed in a Medicare-approved facility. In some situations, it may also pay for the immunosuppressive drugs required to stop the body from rejecting a transplanted lung. 

How Much Does Medicare Pay for Lung Transplants?

If you're approved for Medicare coverage for your lung transplant, Medicare will pay 80% of the approved amount for your procedure and medical care. You are responsible for paying the remaining 20%. You may also be liable for the costs of any drugs not covered by original Medicare, the Part B deductibles and certain facility fees. 

How Much Does It Cost to Get a Lung Transplant?

Lung transplants are likely to cost roughly between $929,600 if you have a single lung transplant and $1,295,900 for both lungs. As these costs are prohibitively high for most people, most lung transplants are financed through federal or private health insurance policies. 

Who Qualifies for a Lung Transplant Through Medicare?

Medicare requires beneficiaries to satisfy several eligibility criteria before agreeing to fund their lung transplant surgery and associated health care costs. Generally, it only considers funding beneficiaries with end-stage pulmonary disease. 

Your doctor will also need to certify that there is no less invasive way to treat your condition successfully and that all other treatment options have been exhausted or are unsuitable. Medicare also requires that your doctor believes you to have decent odds of successful treatment. Certain other factors may also be taken into account when determining eligibility, including your age, overall health status and whether you have the support and capacity to comply with your post-operative care plan.

Does Medicare Pay for Lung Cancer Screening?

Medicare Part B only pays for lung cancer screening using a technique called low dose computed tomography (LDCD) in certain circumstances.

To be eligible, you must be asymptomatic, between the ages of 55 and 77 and seeking lung cancer screening on the instructions of your physician. You must be a smoker or have given up smoking no more than 15 years ago and have a history of smoking roughly 20 cigarettes each day for at least 30 years. If you qualify, you can only receive one LDCD screening per calendar year. Medicare covers 100% of the cost for eligible beneficiaries, so you will have no out-of-pocket costs. 

Does Medicare Part D Help With Lung Transplants?

Although Medicare Part A and B may cover anti-rejection drugs, it may not cover all the medications required before, during and after a lung transplant. You can enroll for Medicare Part D coverage through a private insurance company to help cover the cost of prescription medications. It's wise to enroll in Part D coverage when you enroll in original Medicare in case you suddenly develop a health condition requiring expensive medicines.

Each insurer has a list of drugs that it's prepared to fund, and most companies cover the cost of immunosuppressive medications. However, insurance companies sometimes change the medications they cover, so it's important to check the latest list to ensure that your medication is included. 

Do Medicare Advantage Plans Cover Lung Transplants?

Medicare Advantage plans are sold via Medicare-approved private insurers. Each insurer will have its own rules and eligibility criteria surrounding lung transplant funding. Beneficiaries should contact their Medicare Advantage insurance provider to check if they qualify for assistance before scheduling surgery. 

Does Medigap Pay for Lung Transplants?

Purchasing a Medigap policy through a private insurer can help if you're unable to pay your financial liabilities when you have a lung transplant covered by Medicare. If Medicare agrees to fund your procedure, Medigap insurance can cover some of your deductibles, coinsurance and other expenses.

Does Medicaid Pay for Lung Transplants?

Medicaid may cover lung transplants, but it may not pay for all associated costs. Qualification and funding rules for lung transplants through Medicaid vary from state to state, and you can check the terms of your policy on the Medicaid website. Under Medicaid rules, beneficiaries must have their lung transplant in the same state in which they're registered for Medicaid support. 

How Do I Get a Lung Transplant Through Medicaid?

You will need a referral from your doctor to register with a lung transplant facility. Once you've contacted your chosen facility, you will be assessed to determine if it's a suitable treatment for your condition and circumstances. If you're eligible, you will then be added to an organ waiting list. Medicare will assess your case to decide if you meet its lung transplant funding eligibility criteria.

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