Medicaid Coverage and Authorizations
Because Medicaid covered services and reimbursement policies can vary considerably by state, we cannot describe detailed step-by-step instructions that all centers can follow. Transplant centers should contact their State Medicaid office, or the patients-managed care plan to seek guidance on coverage and authorization requirements.
On this page, we outline general rules and guidelines that apply to most state Medicaid programs. To learn specific details about your state’s Medicaid program requirements, visit Benefits.gov.
How to Determine HCT Coverage
Many state Medicaid programs, and manage care Medicaid plans do not publish their covered indications and medical policies online. Instead, they require transplant centers to submit a request for prior authorization, and requests are reviewed on a case by case basis for ‘medical necessity’. Transplant center staff can call and ask for a list of covered indications. If your center gets a list, you should save it for later use and reference.
Medicaid Requires Prior Authorizations
Every state requires a prior authorization for HCT. In states offering managed Medicaid, the health plan will perform the prior authorization on behalf of the state. Your center should ensure that prior authorization is started as soon as transplant is identified as a potential treatment. Use this Prior Authorization for Transplant Form (DOC) to provide the information Medicaid will need.
Some states require prior authorization for each step of the transplant process, including the evaluation. Contact a patient’s plan or the state Medicaid office immediately upon knowing that transplant is being considered, in order to understand the requirements if your center does not already know the requirements. Remember each plan may have different requirements.
Your transplant center should be sure that at the time of the transplant, the patient still has the same insurance provider that completed the prior authorization. Medicaid, or the patient's managed-care-plan may not cover a transplant that was not prior authorized by the payer prior to transplant.