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.