Insurance may be privately held through an employer or through a personal policy. The terms and benefits through insurance companies for transplant vary widely, so it is best to check with your individual policy to better understand what will and will not be covered.
Some insurance companies will offer a one-time stipend for travel and lodging for transplant patients who have to travel to his or her transplant center for care. Be sure to inquire about this so you can obtain the full scope of your benefits. If you need assistance understanding your insurance policy, the financial coordinator at your transplant center will be able to assist you.
The financial coordinator will be the point person who will be running your insurance and checking your eligibility. In general, you will need pre-approval for evaluation for transplant and then once the transplant team approves you for transplant, the insurance company will need to approve you for the actual transplant.
Referrals and Authorizations
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations (HMOs) require patients to have a referral from their Primary Care Physician/doctor (PCP) before seeing a specialist. A referral is documentation from the Primary Care Provider that they are ‘referring’ the patient to a specialist. The patient must get the referral before the date of the appointment. Without a referral, the HMO will not pay for the visit, and the patient will be responsible for the bill.
In addition to PCP referrals, some insurance companies require prior authorization to begin the transplant process. The patient should call their insurance company before making the first appointment to see what is required by their insurance company.
Many insurance companies are part of a larger network of hospitals and doctors. Insurance companies often contract with transplant networks to manage their transplant cases. Some insurance networks will not approve transplants at a particular center and will require the patient to use a transplant center within their network, even if the preferred center is in another state.
Financial Questions to Ask
How much of the transplant cost is covered by my insurance? (e.g. exactly how much will I have to pay out of pocket)
What financial assistance does the transplant center offer, if any?
What happens if my financial coverage runs out?