Health Insurance and Government Assistance
There are financial assistance programs available to help patients cover transplant care costs.
If you do not earn enough money to support yourself or your family, or if you are unable to work due to a disability, you may qualify for medical assistance.
Medicaid is a jointly funded, federal-state health insurance program. This program covers a variety of individuals including children and low-income or disabled individuals. Medicaid benefits vary from state to state. Medicaid may offer stipends for caregivers who provide care to a Medicaid recipient. Some states may provide travel assistance through Medicaid for transplant such as for lodging, food, or travel.
Learn more about Medicaid and eligibility and coverage in your state here. You can also learn more about Medicaid from the Social Security website.
Medicare is the federal health insurance program for individuals 65 and older, as well as younger individuals with disabilities and those with End-Stage Renal Disease (ESDR). There are several different parts of Medicare that cover specific services:
Part A (Hospital insurance): Covers inpatient hospital stays, skilled nursing facilities, hospice care, and sometimes home health care.
Part B (Medical insurance): Covers certain doctors’ services, outpatient appointments, medical supplies, and preventative services.
Part C (Medicare Advantage plans): A plan offered through a private company that contracts with Medicare to provide you with your Part A and B.
Part D (Prescription Drug coverage): Prescription drug coverage.
Learn more about the different parts of Medicare or visit their website for more information.
AFFORDABLE CARE ACT (ACA)
The ACA is a health care reform law that makes affordable health insurance available to more people. For more information about the ACA, including information about enrollment, visit their website at www.healthcare.gov.
You may be eligible to receive Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) through the Social Security Administration. SSDI and SSI are federal government programs through which qualifying people can receive compensation monthly because they are unable to work due to a disability. Since SSI and SSDI are federal programs, the requirements for both are the same throughout the United States. Please visit www.SSA.gov or contact your local SSA office to determine if you or a patient is eligible.
Here are some guidelines that could entitle a patient to benefits:
Social Security Disability Insurance (SSDI):
- Unable to work for at least one year;
- Physical or mental illness;
- Disabled workers under 65 years and their families;
- Unmarried and disabled persons younger than 22 years with an insured parent or grandparent who is retired, disabled, or deceased;
- Disabled widows and widowers; or
- Benefits are based on a person’s work history or the work history of his/her parents, spouse, or grandparents; it is an “entitlement” program.
Supplemental Security Income (SSI):
- If a person does not qualify for SSDI but is potentially disabled for at least one year and his/her income falls below a certain level;
- Elderly, disabled and/or blind persons with limited income and assets;
- U.S. citizen or legal alien lawfully admitted for permanent residence; or
- Benefits are based on income, living arrangements and other factors that affect financial need; it is a “needs” program.
If you think you may qualify, visit the Social Security Administration online or reach out to your local SSA Office.
Applying for Disability Benefits While on the Waitlist or After an Organ Transplant
An organ transplant represents hope and a renewed lease on life for the recipient, but there is a lengthy healing process involved. During this time, the overwhelming majority of transplant patients are unable to work, which can cause financial stress. Being on a transplant waiting list is regarded as proof of disability due to organ failure, which means a patient could qualify for disability benefits. Organ transplant surgery automatically makes him or her eligible for Social Security Disability (SSD) benefits for one year after his or her surgery, and possibly longer if the condition prevents him or her from holding gainful employment.
What Disability Benefits are Available?
There are two Social Security Administration (SSA) programs designed to provide financial assistance to people with a recognized medical disability. Each one is intended for a different type of applicant and the eligibility criteria are consequently different, but they both provide disabled individuals with extra money to meet living expenses and medical bills.
- Social Security Disability Insurance (SSDI): This program is intended for people who have worked and paid Social Security taxes for a certain amount of time prior to becoming disabled. After a two-year qualifying period, recipients are eligible for Medicare.
- Supplemental Security Income (SSI): SSI does not require a work history, but applicants must have limited financial means and assets, such as the elderly and children. In most states SSI recipients are automatically eligible for Medicaid.
How to Medically Qualify for SSA Benefits with an Organ Transplant
When an individual applies for disability benefits, the SSA will evaluate his or her eligibility by consulting the Blue Book, which is the official catalog of recognized mental and physical disabilities and the medical criteria for each listing. There are various references to organ transplants:
- Section 3.11 – Lung Transplant
- Section 4.09 – Heart Transplant
- Section 5.09 – Liver Transplant
- Section 6.00.E.2 – Kidney Transplant
- Section 7.17 – Bone Marrow or Stem Cell Transplant
The SSA automatically classifies all organ transplant patients as disabled for 12 months after the date their surgery was completed. Those still on the waitlist can also qualify; for example, patients on the heart transplant list who have received 1A or 1B status will automatically qualify for Social Security disability benefits.
After a year has passed, the SSA will re-assess a transplant recipient for signs of residual complications that meet a Blue Book listing and enable the person to keep receiving benefit payments. Examples include:
- Signs of serious organ and system deterioration;
- Graft-vs-host disease;
- Infections that keep recurring; and
- Complications due to anti-rejection medications.
Any transplant reactions that impair a person’s ability to work could result in his or her benefits eligibility to be continued indefinitely.
The Disability Benefit Application Process
When a transplant patient applies for disability benefits, he or she is required to submit an application form and evidence of his or her medical condition. Such documentation might include:
- A physician’s report accompanied by detailed examination notes;
- Imaging scans that visually document the organ deterioration;
- A surgeon’s report covering the transplant itself; and
- Any tests that confirm signs of organ rejection and other residual complications.
Be sure to speak with your doctor if you haven’t received a transplant yet to determine if your organ failure has a good chance of qualifying for benefits.
To learn more about Social Security disability benefits, the eligibility criteria for organ transplant recipients, and how to apply for them, visit the SSA’s website, make an appointment with your local SSA office, or call the SSA toll-free at (800) 772-1213. Once the payments start arriving, your financial stresses will lessen and you can focus on healing.
This information was provided by Disability Benefits Help, an independent organization dedicated to helping people of all ages receive the Social Security benefits they need. If you have any questions, feel free to reach out to them at firstname.lastname@example.org
If you do not earn enough money to support yourself and your family or if you are unable to work due to a disability, you may qualify for government assistance through programs that provide cash assistance and/or Supplemental Nutrition Assistance (formerly food stamps) through the Department of Human Services.
Eligibility guidelines for the Department of Human Services are based on income and assets and vary from state to state. Some states may provide assistance to transplant patients to help with expenses such as lodging, food, or transportation during transplant treatments. It is important to contact or visit the Department of Human Services office in your county to determine if you or the patient is eligible for these programs. Visit their website to see what benefits are available in your state.
The following links provide more information about benefits in DE, NJ, and PA.
Delaware Department of Human Services
New Jersey Department of Human Services