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Financial Resources
Use the advice and resources in this section to help you understand your options, and how to make handling the financial side of transplant a bit easier. This information is not a substitute for getting financial advice from a professional. Be sure you also talk with your transplant financial coordinator, who is trained to assist you with financial matters.
Questions to Ask Your Financial Coordinator
Listed below are questions to ask your financial coordinator. It may be helpful to print out this list and bring it with you to your meeting.
Pre-transplant
Questions to ask before your surgery:
- How much will my transplant cost? How much of the cost will I have to pay?
- What financial coverage does the hospital accept (Medicare, Medicaid, private insurance, etc.)?
- What can I do if my financial coverage runs out?
- Do the costs vary if I have a living donor?
- Is treatment for my medical diagnosis covered?
- Is there a pre-existing clause for my plan? If so, what are the terms?
- Will my illness be considered a pre-existing condition?
- Are there deductible and co-payment amounts? If yes, what are they?
- Is there a co-payment? If yes, how much?
- Are outpatient medications covered under my plan? If yes, is there an approved list of covered medications?
- Does my plan have a list of approved medications? If yes, will the plan ever make an exception if my medication is not included? If yes, how do I request this exception?
- Is there a co-payment for prescriptions? If yes, what is the co-payment?
- Does my plan have a maximum out-of-pocket amount that I would be responsible for each year? If yes, what is it?
- Which costs are used for my out-of-pocket maximum?
- Does my plan have a maximum lifetime amount that it will pay? If yes, how much is it?
- Does my plan have any coverage exclusions? If yes, how long is coverage excluded?
- Is there a limit to the number of transplants I can receive in my lifetime?
- What criteria does my healthcare plan use in selecting providers?
- Are there any restrictions on which transplant centers I can use (designated provider network)?
- Are the transplant centers I am considering within the plan's provider network?
- Does my plan provide coverage for out-of-network providers? If yes, will my out-of-pocket expenses be higher?
- Will my plan cover a consultation at one or more Transplant Centers?
- Do I need pre-authorization for treatment? If so, who may request this approval? To whom should the request be made?
- If I want a second opinion, will my plan cover the cost?
- Does my plan cover expenses such as travel, food, and lodging while I am at the transplant center? Will it cover these expenses for my family?
- If my plan covers travel, food, and lodging costs, how much will it pay? Will it cover the cost of a person to come with me?
- If necessary, how can I report a complaint or appeal my coverage?
- Is there a time constraint for making a complaint or appeal?
- Is there a limit to how many appeals that can be made on my behalf? If yes, what is it?
- Who is my case manager? What is his/her phone number?
- If testing to find a matched donor is covered under my plan, are there limits or exclusions to this coverage? If yes, what are they?
Questions you may have after your surgery:
- What can I do if my financial coverage runs out?
- Are there deductible and co-payment amounts? If yes, what are they?
- Is there a co-payment? If yes, how much?
- Are outpatient medications covered under my plan? If yes, is there an approved list of covered medications?
- Does my plan have a list of approved medications? If yes, will the plan ever make an exception if my medication is not included? If yes, how do I request this exception?
- Is there a co-payment for prescriptions? If yes, what is the co-payment?
- Does my plan have a maximum out-of-pocket amount that I would be responsible for each year? If yes, what is it?
- Which costs are used for my out-of-pocket maximum?
- Does my plan have a maximum lifetime amount that it will pay? If yes, how much is it?
- Does my plan have any coverage exclusions? If yes, how long is coverage excluded?
- Is there a limit to the number of transplants I can receive in my lifetime?
- What criteria does my healthcare plan use in selecting providers?
- Does my plan provide coverage for out-of-network providers? If yes, will my out-of-pocket expenses be higher?
- If necessary, how can I report a complaint or appeal my coverage?
- Is there a time constraint for making a complaint or appeal?
- Is there a limit to how many appeals that can be made on my behalf? If yes, what is it?
- Who is my case manager? What is his/her phone number?
Understanding Your Coverage
Health Insurance
Health insurance provided by an employer, or personal health coverage, generally covers some of the costs related to transplantation. How much your insurance covers will depend on the type of plan. Your transplant center will work with you to make sure that you receive any needed authorization from your insurance company before the surgery. If you have specific questions about your coverage, call your insurance company or talk to your employer.
Medicare Coverage
Medicare is a national health insurance program for people 65 years of age and older, some disabled people younger than 65 years of age, and people with end-stage renal disease (ESRD). If you do not have insurance already, Medicare may be the place to turn for financial assistance for your transplant and your medications. To learn more about Medicare's prescription drug coverage, read the November 2005 Transplant Experience Newsletter. For additional information about Medicare, visit the Medicare website at www.medicare.gov.
Medicaid Coverage
Medicaid is a state health insurance program that helps individuals and families with low incomes pay for some or all of their medical bills. If you are not already enrolled in Medicaid and qualify for coverage, it may be an option for you. For additional information about Medicaid, visit the Medicaid website at www.cms.hhs.gov/medicaid
Maximizing Reimbursement
Sometimes insurance and government programs aren't enough to cover the costs of transplantation. There are organizations that can help people identify resources for transplantation. The following organizations can help transplant recipients with financial issues.
American Kidney Fund
6110 Executive Boulevard, Suite 1010
Rockville, MD 20852
1-800-638-8299
helpline@kidneyfund.org
www.kidneyfund.org
Provides limited grants to needy dialysis and kidney transplant patients and living kidney donors to help with costs of transportation, medicine, and other treatment needs.
Children's Organ Transplant Association (COTA)
2501 COTA Drive
Bloomington, IN 47403
1-800-366-2682
www.cota.org
An organization that strives to make life-saving organ transplants accessible to all. COTA works with individuals of all ages to arrange the necessary funding for transplant expenses.
National Foundation for Transplants
5350 Poplar Avenue, Suite 430
Memphis, TN 38119-3826
1-800-489-3863
info@transplants.org
www.transplants.org
The NFT is a national, nonprofit organization that focuses on helping those seeking a new life through transplantation. NFT provides fund-raising campaigns and grants for transplant recipients.
National Transplant Assistance Fund (NTAF)
150 N. Radnor Chester Road, Suite F-120
Radnor, PA. 19087
1-800-642-8399 (toll-free line)
1-610-535-6105 (local line)
1-610-535-6106 (fax)
www.transplantfund.org
A nonprofit resource serving all organ and tissue transplant recipients, their families, and the professional community that treats them.
Nielsen Organ Transplant Foundation
580 West. Eighth Street, Suite 8000
Jacksonville, FL 32209
904-244-9823
nielsen@notf.org
www.notf.org
Provides financial assistance to pre- and post-transplant recipients in the Northeast Florida area.
Transplant Financial Assistance
The financial responsibilities of transplantation don't end when the recipient is released from the hospital. Costly medications will be needed to protect the new organ, and the patient will require occasional follow-up visits at the transplant center.
The following agencies may help you pay for your anti-rejection medicines:
- Medicare
- Medigap
- State renal programs
- Prescription plans
- Major medical insurance
- Medical assistance programs
- U.S.Veterans Administration
- State programs for the disabled and the aged
If the above sources are unavailable, there are several pharmaceutical companies that provide assistance. The social worker or financial counselor at the transplant center can explain how to apply for assistance.
Most Common Mistakes
A number of common mistakes result in rejected or underpaid claims. It is important that the person in charge of submitting claims review each document for accuracy and content. To help prevent denied claims, we have provided a list of mistakes that are easily avoidable:
- Omission of the provider's number
- Inaccuracies/omission of diagnosis codes
- Transposition/omission of member ID numbers
- Inclusion of an invalid member ID number
- Inaccuracies/omission in the patient's date of birth
- Inaccuracies/omission in the patient's address (city, state, or ZIP code)
- Inaccuracies/omission in procedure codes
- Claim not filed on time
- Date-of-service error
Appealing Denied Claims
Claims may be rejected, or reimbursed at a reduced level, for a variety of reasons (e.g., clerical error, missing procedure codes, date-of-service error) This can be very frustrating, but fortunately you have the right to appeal denied claims. Your transplant financial coordinator can review with you the appeal process specific to your insurance policy and assist you in completing the process. To avoid any further problems, make sure to keep copies of all documents for your records.
Medicare/Medicaid Updates
Medicare and Medicaid are currently changing some aspects of how their programs work. One major change is called “Medicare Part D” - also known as “Medicare Prescription Drug Coverage.” This new program is quite complex, and will work differently for many different types of patients. If you want to learn more about Medicare Part D – click here to access the November 2005 Transplant Experience Newsletter.
Claim Forms
Download health claim forms for Medicare and Medicaid. To obtain all other claim forms, speak with your Transplant Financial Coordinator or contact your insurance company.
CMS-1500 
HCFA-1450 – aka UB-92
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