Alabama Medicaid will cover organ transplants under the following terms and conditions. These terms will apply to all procedures except cornea transplants.

1. (1) Transplants must be performed in the state of Alabama if medically available and appropriate for particular patient and transplant type with the exception of (8)(d) below.
2. (2) All transplant candidates must be from referrals by EPSDT or the primary physician.
3. (3) All transplant evaluations must be conducted by the Medicaid primary contractor. If the primary contractor is unable to perform the transplant, a referral to another facility may be made. The primary contractor will be responsible for coordination and reimbursement of referrals.

4. (4) The following transplants are covered for recipients of any age:

   1. (a) bone marrow,
   2. (b) kidney,
   3. (c) heart,
   4. (d) lung,(single or double)
   5. (e) heart/lung,
   6. (f) liver,
   7. (g) pancreas
   8. (h) pancreas/kidney
   9. (i) liver/small bowel
   10. (j) small bowel
   11. (k) liver/pancreas/small bowel
5. (5) For EPSDT referrals, other transplants may be considered for approval if medically necessary, therapeutically effective, and non-experimental.
6. (6) All transplants must be prior approved by Medicaid. The primary contractor will forward a recommendation packet to Medicaid following evaluation of the recipient. Medicaid will issue notice to the recipient of approval or denial.
7. (7) Recipients who are denied Medicaid coverage for transplants will be offered the opportunity for a fair hearing under the provisions of Chapter Three of this code.

8. (8) Reimbursement.

   1. (a) Reimbursement will be a global payment established by Medicaid. The global payment will include the following:

      1. (1) pre-transplant evaluation,
      2. (2) organ procurement,
      3. (3) hospital room, board, and ancillary services,
      4. (4) out of hospital ancillary services,
      5. (5) post-operative care,
      6. (6) pharmacy and laboratory services, and
      7. (7) all professional fees.
   2. (b) Services provided after discharge will be reimbursed on a fee for service basis.
   3. (c) Reimbursement provisions apply to transplants performed both in state and out-of-state. The global payment represents full payment for all services associated with the transplant. Recipients may not be billed for the difference between the submitted amount and the global payment.
   4. (d) Third Party Payors: Medicaid is a payor of last resort. When a primary payor other than Medicaid has obligated to cover the transplant Medicaid May, at its discretion, approve the payor’s site preference for the transplant.
9. (9) Cornea transplants are covered for defects (as diagnosed by ophthalmologists) which are correctable by transplant.
10. (10) Cornea transplants do not require prior approval.
11. (11) Reimbursement for cornea transplants will be normal Medicaid pricing methodology.
12. (12) Services associated with cornea transplants will be counted in a recipient's regular Medicaid benefit limits.

Author: Karen Smith, Associate Director, Clinic Services/Mental Health Programs

Statutory Authority: Title XIX, Social Security Act; 42 C.F.R. §§405.310(k), 440.10, 440.50, et seq.; State Plan.

History: Rule effective June 10, 1987. Emergency Rule: Effective July 17, 1991. Amended: Effective October 12, 1991. Amended: Filed April 8, 1996; effective May 13, 1996. Amended: Filed December 8, 1997; effective January 12, 1998. Amended: Filed December 7, 1998; effective January 11, 1999. Repealed and New Rule: Filed December 8, 1999; effective January 12, 2000. Amended: Filed July 6, 2000; effective August 10, 2000. Amended: Filed March 14, 2001; effective April 18, 2001. Amended: Filed September 18, 2001; effective October 23, 2001. Amended: Filed November 12, 2013; effective December 17, 2013.