Original Medicare and Medicare Advantage plans both cover certain types of approved stem cell therapy.
Medicare Parts A and B, also known as Original Medicare, provide coverage for approved stem cell treatments and the associated out-of-pocket costs. However, coverage varies between the different Medicare options.
The purpose of Food and Drug Administration (FDA)-approved stem cell therapy is to restore typical blood production and development in a person whose body has lost this function.
This article discusses this type of stem cell therapy, examines the coverage and costs of each part of Medicare, and describes the specific procedures that Medicare covers. It also looks at the costs of inpatient stem cell therapy for people who do not have Medicare.
Glossary of Medicare terms
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person needs to self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers part of the costs of two types of
Medicare Part A, which is hospitalization insurance, covers inpatient transplants. However, Part A pays only for admissions that fall under a regulation called the Two-Midnight rule. According to this rule, the admitting doctor expects a person to require a stay in the hospital for at least two midnights.
Although Part A is generally not appropriate for shorter hospital stays, Medicare may grant coverage on a case-by-case basis, depending on the admitting doctor’s judgment.
The cost relating to Part A in 2024 is a $1,632 deductible. There is a $0 coinsurance for the first 60 days of a hospital stay.
Part B, which is medical insurance, covers outpatient transplants that healthcare professionals consider medically necessary.
The yearly deductible of $240 applies. Once a person meets the deductible, they usually pay 20% of the Medicare-approved amounts for doctor services and other costs involved in the therapy.
Medicare Advantage (Part C) provides the overage for parts A and B, while most plans also include prescription drug coverage.
Private insurance companies administer Medicare Advantage policies, and because of this, the out-of-pocket costs are different from those of Original Medicare.
Out-of-pocket costs may also vary among plans, but all policies have a yearly cap on expenses. Additionally, an individual with Medicare Advantage must go to an in-network provider.
Read about the advantages and drawbacks of Medicare Advantage plans.
Medigap is Medicare supplement insurance. People who have Original Medicare may buy a Medigap plan, which helps them pay out-of-pocket costs relating to parts A and B. The costs that this plan generally covers can include:
- deductibles
- copays
- coinsurance costs
Learn more about Medigap plans and costs.
Someone with original Medicare is eligible to enroll in a Part D plan for prescription drug coverage, which includes medications necessary for stem cell therapy. Part D deductibles, copayments, and coinsurance costs vary according to the policy a person has purchased.
Learn more about Medicare Part D costs.
Medicare only covers two stem cell procedures: allogeneic hematopoietic stem cell transplantation (Allo-SCT) and autologous stem cell transplantation (Au-SCT).
Allo-SCT
In Allo-SCT, a healthcare professional delivers healthy donor stem cells to a person through an intravenous infusion via the veins. The purpose is to restore typical blood production in someone whose body cannot perform this function.
A candidate for the transplant may be an individual with a deficiency in blood production, which can either be an inherited or acquired deficiency. An example could be someone with severe aplastic anemia.
Before the transplant, an individual will receive treatment to weaken the immune system — such as chemotherapy, radiation therapy, or both — so their body will not reject the donor cells. This treatment also allows the donor cells to reach the bone marrow, where they grow and make new blood cells.
This procedure may have complications, including rejection of the donor cells despite the treatment to weaken immunity. Another possible complication is that the donor’s immune cells may attack a person’s healthy cells.
In addition to helping the beneficiary with costs, Medicare also assists the donor with costs. Covered donor expenses include doctor services, hospital care, and follow-up care.
Au-SCT
An Au-SCT procedure restores stem cells without the help of a donor. The transplant aims to enable the body to resume blood production and development after the organs and tissues sustain damage.
Candidates for the transplant include those with blood cancers, such as lymphoma or leukemia.
Before an Au-SCT transplant, a health professional
If the procedure is effective, the transplanted cells make new blood cells within the bone marrow.
Au-SCT has a higher relapse rate than Allo-SCT, but because it does not involve donor cells, Au-SCT does not carry the risk of a healthy cell attack.
Stem cell therapy can be expensive. According to Hope Stem Cell Network (HSCN), the cost of stem cell therapy can range from $5,000 to $50,000. The cost generally depends on the type of stem cell therapy and the dosage.
The HSCN also states that the average cost of stem cell site injections is $2,000 to $5,000. The average cost for expanded or increased dosage cell products is $20,000 to $55,000.
Individuals can contact Medicare to find out more information on the coverage for stem cell therapy.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
People with Medicare are eligible for coverage of two types of stem cell transplants. Candidates for these therapies may include individuals with a blood disorder, such as aplastic anemia, or someone with blood cancer, such as lymphoma.
A person with Original Medicare can enroll in a Medigap plan, which helps with out-of-pocket expenses. An individual with a Medicare Advantage plan will have out-of-pocket costs that differ from those of Original Medicare.
Note that stem cell therapy is costly. Before undergoing one of the transplants, a person may wish to check their Medicare plan to get an estimate of both covered and out-of-pocket costs.