Medicaid Benefit Information

 

Benefit: Transplant Services Organ and Bone Marrow

Definition: Bone marrow transplants are performed for the treatment of certain types of cancers and when the bone marrow fails to produce enough red/white blood cells and platelets; organ transplants are performed when an organ fails because of illness.

Acceptance as a candidate for covered transplant services is determined by the designated transplant hospital, not by Medicaid. Pre-transplant and post-transplant care, including medications, are covered by Medicaid even if the transplant is not a Medicaid covered transplant.

Limits:  Medicaid reimbursement for transplant services has the following limitations:

  • All out-of-state transplant referrals for organ and bone marrow transplants must be requested by a Medicaid designated transplant center. The prior authorization must be forwarded to the Medicaid office for review;
  • Out-of-state evaluations and transplants are not covered if the services are available in the state of Florida;
  • Physician services limitations apply; (see that benefit above)
  • Recipients age 21 and older are eligible for kidney, cornea, liver, lung, heart and bone marrow transplants when medically necessary and appropriate; and
  • Recipients 20 years of age or younger are eligible for transplants determined medically necessary and appropriate.

Adult heart, liver and lung transplants, and pediatric lung transplants require prior authorization. Medicaid does not reimburse transplant procedures that are deemed investigational or those not yet proven clinically effective as determined by consultants within the Agency Organ Transplant Advisory Council.

Exceptions: Medicaid reimburses for pre-transplant and post-transplant related services even if the transplant itself is not a covered service.
Medicaid does not reimburse for donor services for solid or bone marrow transplant procedures even if the donor is a Medicaid eligible recipient.

Co-pays: None

Reform items that can vary: None