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Does Insurance Cover Stem Cell Therapy

Does Insurance Cover Stem Cell Therapy?

Today, stem cell therapy makes it possible to treat many diseases, giving people hope to overcome leukemia, Parkinson’s disease, Types 1 and 2 diabetes, and other serious diseases. But not everyone can afford this expensive treatment. According to “The Niche” study, patients can expect to pay from $2,500 up to $100,000 or more for stem cell treatment. So, it is only natural that most of these people wonder if stem therapy is covered by insurance.

Read more about: How Much Does Stem Cell Therapy Cost: Detailed Review

Unfortunately, this is a rather complicated and controversial issue, and there are no easy answers. But after conducting extensive research, we are ready to answer all your questions regarding whether health insurance covers stem cell therapy in 2020.

Medicare and private health insurance: pros and cons

What is health insurance?

After purchasing an annual policy, an individual receives certain coverage for medical care within the budgets and allowable services that are provided for them upon the occurrence of an insured event (illness or injury). The allowable budgets, services, and facilities depend on the specific insurance company, the cost of the policy, as well as the patient’s age and state of health.

What is Medicare?

Medicare is a federal health insurance program created for:

  • people over 65 years old;
  • some young people with certain disabilities;
  • patients with end-stage renal disease (ESRD) or Lou Gehrig’s disease (ALS).
  • The program is funded partially by payroll taxes levied on both employees and employers, as well as monthly contributions deducted from Social Security benefits. The program helps pay for medical care, but it does not cover all medical expenses or the cost of most types of long-term care.

    Medicare is currently divided into four parts:

    • Part A: Time spent at a facility and related services are paid.
  • Part B: Helps pay for doctors and other specialists, outpatient care, healthcare at home, some medical equipment, and some preventative services. Involves a monthly fee.
  • Part C: (or Medicare Advantage): Offers the benefits of Parts A, B, and D, and is managed through private insurance firms.
  • Part D: Covers drug prescriptions. This is optional – you can get it separately, or with part C.
  • The pros and cons of Medicare and private health insurance

    The main difference is that under the terms of Medicare, the patient receives care at public health system institutions. Private insurance implies receiving patient care in private clinics and other medical institutions.

    Other pros and cons of Medicare and private health insurance:

    Medicare1. Covers you 100% for the MBS fee for GPs and 85% for the MBS fee for specialists.1. You can’t choose your preferred doctor or hospital. Your choices will depend on where you live.
     2. If your doctor bulk bills, you pay nothing out of pocket.2. You usually can’t choose when you’ll be admitted. Waiting times can be longer than for private hospitals.
     3. Covers many tests, examination, pathology tests, eye tests, and procedures by doctors.3. No coverage for private patient costs.
     4. Covers you for part of the cost for PBS prescription medications.4. No overseas coverage for medical and hospital costs.
     5. Hospital care in a public hospital as a public patient is free.5. No coverage for services that aren’t clinically necessary (such as cosmetic surgery).
      6. Does not cover you for ambulance services.
      7. No coverage for ancillary services like dental, physiotherapy, occupational therapy, and other services and products, like optical.
    Private health insurance1. Choose your doctor, hospital, and admission time.1. Might not cover you for total services provided in hospital, so you might need to pay out-of-pocket costs.
     2. Get covered for ancillaries like physiotherapy, dental, optometry, and podiatry that are not covered by Medicare.2. Waiting periods can apply for different treatments.
     3. Retain the option of a choosing public hospital.3. Comes with exclusions and restrictions limiting your coverage.
     4. You could have a better chance of having your own private room if you need hospital treatment.4. Long-stay patients (35 successive days) usually need to pay more out of pocket.
     5. Government subsidises some of your premiums through the Private Health Insurance Rebate, although you might need to pay the Lifetime Health Cover loading and Medicare Levy Surcharge if you don’t have hospital insurance. 
     6. Different tiers to suit your life stage, requirements, and budget. 

    So, does insurance cover stem cell therapy?

    Usually, when it comes to stem cell injections in clinics, medical insurance does not cover such treatment. However, there are some approved techniques for stem cell treatment. These include:

    • bone marrow transplants for cancer and aplastic anemia treatment;

    • cord blood transfusion for the treatment of blood cancers.

    As with health insurance, Medicare also wouldn’t cover stem cell injections. However, in the case when the patient’s attending physician considers a particular type of stem cell therapy necessary, then the program can provide coverage for such a treatment.

    Let’s take a closer look at this issue and learn about the nuances of health insurance and Medicare coverage of stem cell treatment.

    Insurance companies have difficulties covering many existing types of cell therapy. For example, Aetna, the third-largest medical insurance company in America, does not support stem cell therapy (including platelet injections) because of its experimental nature.

    Anthem, the second-largest insurance company in the US, also does not consider stem cell injections medically necessary.

    If your condition warrants stem cell treatment, we strongly recommend getting as much information about it as you can.

    How to do this without numerous, prohibitively expensive consultations? Start with your insurance company: even if it is not paying for stem cell treatment as such, it may pay for your consultation with the doctor and other related expenses incurred during a stem cell procedure.

    Amy Andrew’s story

    Amy was extremely surprised to see an advertisement from a new medical provider in California reporting that stem cell and platelet transplant procedures were covered by Medicare, because such treatment is considered outpatient and is not covered by health insurance companies. Amy asked her insurance carriers if there were any changes regarding this situation; they said no, as she expected.

    Turning to the company advertising the above-mentioned services, she was told that the procedure is covered by many insurance companies, but only after the consideration of certain insurance conditions.  Even if Amy had Medicare, she would have to pay for the “kit” used to take stem cells from the bone marrow. Only the injection itself will be covered.

    This is one of many examples of misleading activities of insurance companies. Always double-check the fine print of your health insurance before using stem cell therapy services.

    Read more about Regenexx procedure review

    Does Medicare pay for stem cell therapy (in detail)?

    Medicare covers only some of the existing stem cell treatments, with the proviso that only a part of the total cost of treatment is paid. For approved stem cell therapies, patients are covered by Medicare Parts A and B. Treatments such as stem cell transplantation are also covered, and this coverage even extends to non-Medicare medical facilities.

    If the prescribed stem cell therapy is part of an outpatient procedure, there is a chance that Medicare Part B will cover it. In this case, patients usually pay 20% of the coinsurance approved by Medicare for the therapy prescribed. The patient pays the Part B coinsurance after meeting the deductible, which is $198 per year in 2020.

    If the prescribed therapy involves inpatient procedures, they are covered by Medicare Part A. In this case, the patient pays the Part A deductible ($1,408 for the benefit payment period in 2020) before coverage begins.

    Typically, Part A coinsurance is determined by the time spent in a medical center. The amount includes the following items (for 2020):

    • $0 coinsurance for two months spent in a hospital;
  • $352 coinsurance for the third month;
  • $704 coinsurance per each lifetime reserve day after a three-month period for each benefit period. Beyond that, the patient is responsible for all expenses.
  • One of the most sought-after medical services covered by the program is the transplantation of hematopoietic stem cells (coverage is provided under certain conditions) for diseases/conditions such as:

    • Myelodysplastic Syndromes (MDS);
  • Leukemia;
  • Wiskott-Aldrich Syndrome;
  • Severe Combined Immunodeficiency Disease (SCID).
  • Another procedure that Medicare may cover is autologous stem cell transplantation for diseases/conditions such as:

    • Advanced Hodgkin’s Disease;
  • Acute Leukemia in remission;
  • Recurrent Neuroblastoma;
  • Resistant non-Hodgkin’s Lymphomas.
  • Janice McClenahan’s story

    In September 2018, Janice McClenahan was diagnosed with a rare double-hit lymphoma blood disease. Neither chemotherapy nor stem cell transplantation helped Janice.

    However, her attending physician at the Siteman Cancer Center felt there was still hope for a cure with “CAR-T,” an innovative type of personalized immunotherapy. The treatment involved the use of FDA-approved Yescarta medication. The problem was that the treatment cost $1.5 million. However, McClenahan was told that her treatment would be covered by Medicare and additional health insurance.

    In May of 2019, one month after completing treatment, Janice McClenahan’s disease was finally defeated, and in August of that year, the Medicare & Medicaid Services Centers reported that CAR-T therapy would be covered for all Medicare patients.

    Because most stem cell treatments have still not been thoroughly researched, only some of them are FDA-approved, and patients should carefully study the list of approved procedures, as well as the conditions of their insurance. This is necessary to avoid misunderstandings between the patient, the insurance company, and the medical center. Doing so will also help to avoid potential ineffective and even dangerous types of stem cell treatment.

    Read also:

    What Property Is Unique to Stem Cells?

    Difference Between Embryonic and Adult Stem Cells?

    Stem Cells: Multipotent, Totipotent, Pluripotent, Unipotent

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