TONI SAYS: Is at-home recovery after a transplant covered by Medicare?

Mar. 11—Dear Readers: This week, I received a text message from a local Toni Says Medicare client that I would like to share with you:

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. Thanks in advance.

—name withheld

To My Readers: This text made me realize that America is not prepared for a life-changing medical need such as a transplant.

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

Page 52 of 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 that you must have Part B at the time you get immunosuppressive drugs. You pay 20% of the Medicare-approved amount for the drugs and the Part B deductible applies. Medicare drug coverage (Part D) covers immunosuppressive drugs if Part B doesn't cover them.

I would advise Toni Says readers to enroll in Medicare Parts A, B and D (Medicare's prescription drug plan) when not working full-time and covered under your or your spouse's employer benefits.

Have a complete Medicare Part D prescription drug planning consultation before enrolling in a Medicare Part D plan whether applying for Original Medicare for the first time or changing your Part D plan during Medicare's Annual Enrollment Period, October 15-December 7 every year.

Be sure that the Part D plan you choose covers all your transplant drugs as well as prescriptions you take daily. If your Part D plan does not cover your transplant prescription drugs, then who will pay? You will! (Chapter 5 of Toni's Medicare Survival Guide Advanced edition explains Medicare Part D in depth and how to enroll properly.)

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."

The handbook continues, "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 Toni Says client's question about Medicare paying for at-home care while he is recuperating from his liver transplant, I did not have good news for him.

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

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

I have informed the Toni Says client to begin speaking with at-home provider services, friends, and family about receiving their help with round-the-clock care at home to aid him and his wife. 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. She has spent nearly 30 years as a top sales leader in the field. If you have a Medicare question or want to discuss long-term care options, email info@tonisays.com or call 832-519-8664. The "Medicare Survival Guide Advanced" edition is available at www.tonisays.com.

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