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Second Wind Lung Transplant Association

Private Insurance

You and your family may have health insurance coverage through your employer or a personal policy. Most insurance companies today offer at least optional coverage for transplant costs, but the terms and the extent of the coverage vary widely. Read and reread your policy carefully then be sure to contact your insurance policy provider and ask all of your questions again, especially the ones to which you think that you already have the answers to, after rereading your policy. Keep asking the questions until you understand the insurance company’s position.

You will need to determine whether your insurance will pay for medication, follow-up lab tests and clinic visits following the transplant. Also, don’t forget the organ recovery charges associated with the transplant procedure. Usually insurance pays about 80 percent of hospital charges. That means that you must cover the remaining 20 percent from other sources. Be sure to pay your premiums on time so that your policy will not lapse.

Most of the health insurance policies have some sort of lifetime maximum amount of coverage or “CAP.” Once the patient has reached this CAP the insurance company does not have to pay any additional benefits. The amount of these CAPs vary greatly depending on your individual insurance policy. These CAPs may apply to just one procedure or treatment, or to all combined procedures, treatments and medications. Even after the actual transplant, the ongoing cost of care may exceed the CAP. It is very important for you to be familiar with the amount and terms of your insurance CAP. After your review of your insurance coverage and you still have unanswered questions, you might want to contact the office of your State Insurance Commissioner.

Some insurance companies may consider you “uninsurable” if your medical expenses exceed the amount of the insurance the provider can pay. More than half (25)of the states have “High Risk Insurance Pools,” which are state programs to provide benefits to some people who are uninsurable. In some states you might qualify for a “Community Rate” plan offered as a nonprofit service by some insurers. You will still have to pay insurance premiums to participate in these plans. The premiums are usually more expensive than an average insurance premium. You can contact your State Insurance Commissioner to find out if these options are available to you.

In all cases, it is best to make all of the necessary arrangements with your insurance company prior to the transplant procedure. Most insurance companies require prior authorization (approval) for organ transplant procedures. Your transplant center social worker or financial counselors can help you with the information that you will need to complete the prior authorization process. You may also contact advocacy and charitable organizations or your legal advisor to help you in arranging with your insurance provider.

Medicare Rights Center

The Medicare Rights Center (MRC) is a national, not-for-profit, non-governmental organization that helps ensure that older adults and people with disabilities get good affordable health care. MRC provides telephone hotline services to individuals who need answers to Medicare questions or help securing coverage and getting the health care they need. Their education department works to teach people with Medicare and those who counsel them–health care providers, social service workers, family members, and others–about Medicare benefits and rights. The organization has just launched a free newsletter titled “Dear Marci.” From ANM. Read about it at: Medicare Rights website.