Should be covered under a patient`s Medicare Part D plan. Include

Report
Assisting Your Patient Through
the Transplant Process
Why Does a Patient Choose
Transplant


Avoid dialysis
Improve quality of life

Continuation of life goals








Work
Family
Hobbies/interests/travel
Fewer diet restrictions
Live longer
Doctor or staff tells them to do it
They have a living donor
Family pressures
Waiting List
5/3/10

All








107,223
Kidney
Pancreas
Kidney/Pancreas
Liver
Intestine
Heart
Lung
Heart/Lung
84,672
1,455
2,181
15,954
244
3,143
1,841
81
Waiting Times




O >1771 days (approx. 5 years)
A >1144 days
B >2003 days (approx. 5 years)
AB >732 days
Improving Transplant Outcome Begins
Long Before the Transplant




Assess the whole picture
Individualized Plan

Assessment of resources

Plan to meet need
Medical contraindications
Psychosocial contraindications




Financial
Support
Adherence to medical recommendations
Mental Health/Psychiatric Issues

Depression; Substance abuse
Psychological Issues

Psychological or Psychiatric evaluation
recommended




Substance abuse, psychiatric history
Will patient be able to adhere to medical
recommendations for transplant
Ongoing counseling indicated to adapt
to transplant regimen
Adherence assessment and plan
What the dialysis social worker
can do and why

Kidney Health Care




Apply even if it’s only for travel
AKF can no longer pay for Medicare
supplement after transplant.
 Usually patient cannot pay and supplement
ends.
 KHC will pay 20% for anti-rejection meds
not covered by Medicare Part B if patient
does not have Medicare supplement.
If patient loses EGHP, KHC will cover 4 meds
with EGHP termination notice.
When transplant patients need meds, they
need them quickly to avoid transplant
rejection!
What the dialysis social worker
can do and why

Keep KHC record updated with current
insurance, including Medicare
supplement info.

If this is not kept up to date, billing for
anti-rejection meds can be billed
incorrectly immediately following
transplant. This can cause patient not to
get anti-rejection medications.
What the dialysis social worker
can do and why

Choose the most cost effective Medicare
supplement possible




If there is any chance of patient paying this cost
post transplant, it needs to be the lowest cost
possible
Educate yourself on changes to the
supplement plans. Several will no longer
cover full 20% co-insurance.
Assess for Medicaid/QMB/SLMB/QI-1
Educate the patient re AKF and post
transplant guidelines
Costs and Side Effects
For your knowledge and
background
Anti-rejection Medications (cost without insurance)
Prograf
Headache, nausea, diarrhea, high blood sugar,
tremors, excessive hair growth, trouble sleeping,
high blood pressure, swelling, high cholesterol/
triglycerides sleep problems, mood swings,
abnormal liver function
5 mg twice a
day
$888.89 per
month
Neoral
Headache, tremors, abnormal kidney function, high
blood pressure, high blood sugar, hyperlipidemia,
excessive hair growth, gum over growth, sleep
problems, mood swings, seizures
200 mg twice
a day
$737.84 per
month
Cellcept /
Myfortic
Nausea, vomiting, diarrhea, stomach cramping,
headache, low white blood cell count, low red
blood cell count, low platelet count
1000 mg twice
a day
$572.36 per
month
Prednisone
Fluid retention, swelling of face, high cholesterol &
triglycerides bone disease, stomach ulcers, acne,
mood swings, anxiety, weight gain, increased blood
sugar, cataracts, bruising
10 mg once a
day
$7.16 per
month
Rapamune/
Zortress
High cholesterol, high triglycerides, high blood
pressure, rash, acne, low platelets, diarrhea
2 mg once a
day
$416.00 per
month
These meds remain covered under Medicare Part B for most people rather than
Part D.
Side Effects of Medications

swelling of feet,
hands, abdomen, or
face

anxiety

mood swings

trouble sleeping

tremors (shaking)

nausea, diarrhea

headache

unwanted hair
growth


increased appetite
changes in fat and
sugar metabolism

weight gain

hair loss

high blood pressure

gum overgrowth




tingling hands and
feet
vomiting
increased risk of
infection
increased risk of
cancer
Some Medical Costs that come
with Transplant






the hospital stay and surgery (Medicare
deductible, $1100)
additional hospital stays for complications
(Medicare deductible, $1100 per 60 day
admission)
follow-up care and testing
anti-rejection and other drugs, which can easily
exceed $10K per year;
fees for surgeons, physicians, radiologist, and
anesthesiologist
insurance deductibles, out of pocket expenses
and co-payments (Medicare and/or Employer
Group Health Plan)
Other Meds Commonly
Prescribed at Discharge
Valcyte (needs to be on
Part D formulary)
Mycelex (clotrimazole)
PPI (nexium, protonix
(pantoprazole), aciphex,
prevacid, kapidex,
omeprazole)
Blood pressure meds
$2700/month (needed first
3 months after txp)
$200 (needed 6 weeks
after txp)
Stomach meds
Should be covered under a patient’s Medicare Part D plan. Include these
if you are helping a pre-transplant patient determine the best Part D plan.
Part D and other
Creditable Coverage

Issues of having both Part D and EGHP



Denial of coverage
COB
Auto enrollment in Medicare Part D if
enrolled in Medicaid even temporarily
Non Medical Costs
Transportation (to and from
transplant center; to and from
follow up visits—about 13 1st
month)
Food while staying near
transplant center
Lodging (6 weeks) while
staying near transplant center
$15-$25 a day
($15 x 42= $630)
$40-60 a day
($40 x 42= $1680)
Lost wages (8 weeks)
Dependent care
Children should not come
with patient for transplant!
Freedom?
A transplant
does not mean
the end to
seeing doctors,
going to clinic,
taking lots of
pills, staying on
a diet, etc.
What to Expect


The first 3-4 months after transplant
can be a difficult period for the patient
and the family
50% of people go back into the hospital
at least once during the first 6 months
post op


Rejection episodes can be anticipated
Debt accrues due to loss of insurance,
loss of wages, medical costs
What to Expect

Problems with access to insurance

Medicare terminates 36 months after
transplant unless the patient has another
disability or if over 65
After Medicare ends, options include





EGHP
High risk insurance pools
VA
Medicaid
Help the Patient Prepare Early
for Return to Employment




Social Security Review usually occurs within
12-18 months after transplant.
If patient was disabled solely on ESRD, they
will no longer be considered disabled as early
as 12 months following transplant.
LTD will also end unless there is an ongoing
disability.
Help the patient to begin thinking of
rehabilitation early
Help the patient remember..

To receive full Medicare benefits for a
transplant, you must go to a Medicare approved
facility



If the person has their transplant in another country,
Medicare Part B will not cover the anti-rejection
medications
The anti-rejection meds create huge problems with
Part D donut hole
Medicare Part D does not cover anti-rejection
meds if person qualifies under Part B for
coverage.
Medicare Issues

Patients can choose to wait to sign up for Part A
at the time of transplant
 They can wait to take Part B until they need it

Must plan ahead to avoid a gap in coverage


Coordination of benefits (COB)
Applying for Medicare Part B if Part A is in place



Can only apply during January-March
Medicare Part B becomes effective July
Can usually apply for Part B at time of transplant
What the Dialysis Social
Worker Can Do and Why

If Medicare Part B is terminated, notify
transplant center, as anti-rejection
medications WILL NOT be covered until
it is reinstated.
Medicare Issues


Medicare must be effective the month
of the transplant for the anti-rejection
meds to ever be covered by Medicare
Part B
If someone is on COBRA, this can have
the implication of losing COBRA.
Desired Outcome of Transplant
Psychosocial Assessment and Education







Plan
Plan
Plan
Plan
Plan
Plan
Plan

for
for
for
for
for
for
for
Access to Medications
Caregiver and Support
Lodging
Transportation
Fundraising
Employability
Insurance after Transplant
To promote improved transplant outcomes
Fundraising

Patients and families often use public fundraising to
help cover expenses not paid by medical insurance. It
is a good idea to ask for assistance in planning,
promoting, and carrying out these activities.




The transplant social worker or coordinator will often need to
help complete part of the application
National Transplant Assistance Fund
(800) 642-8399; www.transplantfund.org
National Foundation for Transplants
(800) 489-3863; www.transplants.org
Children's Organ Transplant Association
(800) 366-2682; www.cota.org
Resources

Kidney School
www.kidneyschool.org

American Association of Kidney Patients


Life Options Rehabilitation Resource Center


www.lifeoptions.org; 800/468-7777
National Kidney Foundation


www.aakp.org; 800/749-2257
(800)/622-9010; www.kidney.org; Transaction Council
United Network for Organ Sharing

(888) 894-6361; www.unos.org
Mary Beth Callahan, ACSW/LCSW
Dallas Transplant Institute
214/358-2300, 6290
[email protected]

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