Will Medicare cover at-home recovery from transplant?

This week, I received a text message from a local Medicare client that I would like to share:

“Toni, I need to put together a 24/7 home care recovery plan after a liver transplant. The surgery is over a year out, but I would appreciate tips on how to plan for this medical event.”

This text made me realize how unprepared many Americans are for a life-changing medical situation such as a transplant.

Luckily, my client has original Medicare with a supplement, allowing him and his medical team to pick which skilled nursing/rehab facility and home health agency he will use while recuperating from his liver transplant.

The 2024 “Medicare & You” handbook under “Transplants & immunosuppressive drugs” states that you must have Part A in place at time of the covered transplant and when you get immunosuppressive drugs. You pay 20 percent of the Medicare-approved amount for the drugs, and the Part B deductible applies. Medicare Part D covers immunosuppressive drugs if Part B does not.

I advise readers to enroll in Medicare Parts A, B and D when not working full time and not covered under employer benefits.

Have a complete prescription drug plan consultation before enrolling in a Part D plan whether applying for original Medicare for the first time or changing your Part D plan during Medicare’s annual enrollment period, Oct. 15 through Dec. 7.

Be sure that the Part D plan covers all your transplant drugs as well as prescriptions you take daily. If it does not cover your transplant drugs, then who will pay? You will.

The Medicare handbook also states, “Medicare covers doctor services for heart, lung, kidney, pancreas, intestine and liver transplants under certain conditions, but only in Medicare-certified facilities.

“If you’re thinking about joining a Medicare Advantage plan and are on a transplant waiting list or believe you need a transplant, check with the Medicare Advantage plan before you join to make sure your doctors, other health care providers, and hospitals are in the plan’s network. Also, check the plan’s coverage rules for prior authorization and coverage for your living donors.”

Regarding the client’s question about Medicare paying for at-home care while he is recuperating from his liver transplant, I did not have good news.

Original Medicare pays zero for at-home care while recuperating from a transplant or illness. Medicare will pay for home health visits if there is a doctor’s order and it meets Medicare’s medical requirements.

Medicare will pay only for skilled nursing or rehab facility care. If you do not meet Medicare’s qualifications for skilled nursing, you will pay 100 percent of the cost out of pocket.

I have urged this client to begin speaking with at-home provider services, friends and family about receiving their help with round-the-clock care at home. If he has a long-term care policy, it may pick up costs not paid by Medicare.

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.