1.0 POLICY
1.1 Donor costs
are covered when:
1.1.1 Both the donor and recipient are beneficiaries.
1.1.2 The donor
is a beneficiary but the recipient is not.
Note: This policy does not supersede the provisions
of Title 10, United States Code (USC) Chapter 55, Section 1079,
which stipulates that TRICARE is always second pay, except to Medicaid.
If the recipient has Other Health Insurance (OHI), the OHI is primary
payor for donor costs. TRICARE will cover donor costs when the recipient
does not have OHI or the donor costs are not covered by the OHI.
(See the TRICARE Reimbursement Manual (TRM),
Chapter 4, Section 4.)
1.1.3 The donor
is the sponsor and the recipient is the beneficiary. (In such an
event, donor costs are paid as a part of the beneficiary and recipient
costs.)
1.1.4 The donor is neither a beneficiary nor a sponsor,
if the recipient is a beneficiary. (Again, in such an event, donor
costs are paid as a part of the beneficiary and recipient costs.)
1.2 If the
donor is not a beneficiary, TRICARE benefits for donor costs are
limited to those directly related to the transplant procedure itself
and do not include any medical care costs related to other treatment
of the donor, including complications.
1.3 In most instances, for costs
related to isolated kidney transplants, Medicare (not TRICARE) benefits
for end-stage renal disease will be applicable.
1.4 If a beneficiary
participates as a kidney donor for a Medicare beneficiary, Medicare
will pay for expenses in connection with the kidney transplant to
include all reasonable preparatory, operation and postoperation
recovery expenses associated with the donation.
2.0 EXCLUSIONS
2.1 Services
and supplies provided as a part of or under a scientific or medical
study, grant, or research program.
2.2 Services and supplies not
provided in accordance with accepted professional medical standards;
or integral to an unproven procedure.
2.3 Donor transportation costs.