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.
