US finalises donor-income rules for living organ donor reimbursement

The Health Resources and Services Administration has finalised new eligibility guidelines for the Living Organ Donation Reimbursement Program, shifting the basis for a donor's eligibility from the organ recipient's finances to the donor's own household income [s1]. The change implements the Honor Our Living Donors Act, enacted in February 2026, which prohibits considering an organ recipient's household income when determining a living donor's eligibility for reimbursement [s1]. HRSA published the final notice in the Federal Register on 29 September 2026 [s1].

What the program does

The reimbursement program operates under section 377 of the Public Health Service Act, which directs the Secretary of Health and Human Services to reimburse eligible living donors and donor candidates for qualifying expenses, with a preference for people the Secretary judges less able to meet those costs on their own [s1]. Since 2007 the program has covered qualifying non-medical expenses, including travel, meals, lost wages, and child and elder care, up to $6,000 per organ donated, for costs tied to donor evaluation, the donation surgery and follow-up care within two years of the procedure, or beyond that period in exceptional circumstances [s1].

HRSA reports that since its inception the program, currently run by Mayo Clinic Arizona and the National Living Donor Assistance Center under a cooperative agreement, has received more than 21,000 applications and approved nearly 89 percent of them, facilitating over 12,000 living organ donations [s1].

The change the HOLD Act forced

Previously, a donor's eligibility was linked to the organ recipient's household income, so a donor's access to financial help could depend on the finances of the person receiving the organ. The HOLD Act bars that linkage [s1]. HRSA first set out proposed replacement guidelines in a 1 July 2026 Federal Register notice and sought public comment [s2].

The proposed framework was donor-centred, with a first priority category for donors with household incomes at or below 350 percent of the HHS Poverty Guidelines, a second category for incomes above 350 but no more than 500 percent, and a capped financial hardship waiver for donors above 500 but no more than 750 percent [s1]. HRSA received 44 comments, from former living donors, transplant centres, organ procurement organisations and stakeholder groups [s1]. No commenter opposed the overall shift from a recipient-income framework to a donor-income one, and 34 explicitly supported the donor-centred approach [s1].

What changed between the proposal and the final rule

HRSA made two notable changes in response to comments. First, it dropped a plan to open the second priority category only later in the funding period, subject to available money, and will instead let applicants apply to all priority categories from the start of the project period [s1]. Commenters had warned that a phased opening could produce inequitable outcomes for donors in similar financial circumstances depending only on when they applied, and could delay donations while a recipient's health declined [s1]. HRSA said it will monitor application volume and spending and give transplant centres and the public advance notice if funding is insufficient for the lower categories [s1].

Second, HRSA created a separate third priority category for the financial hardship waiver population, donors with household incomes of 501 to 750 percent of the HHS Poverty Guidelines, rather than folding them into the second category [s1]. Commenters argued that a distinct category would ease administrative burden and avoid subjecting lower-income applicants to hardship-documentation requirements meant for a different group [s1].

HRSA declined to eliminate income thresholds entirely, noting that the authorising statute requires a preference for donors "more likely to be otherwise unable to meet such expenses", which it said makes income parameters necessary [s1]. It also declined, for now, to build in regional cost-of-living adjustments, citing the administrative complexity, while saying it would keep evaluating whether such adjustments are warranted in a future revision [s1].

Why it matters

Living donation depends on people willing to undergo surgery and recovery to give an organ, often a kidney, to someone else, and the out-of-pocket costs of doing so, lost wages and travel in particular, can deter donors who cannot absorb them. By tying help to the donor's own means rather than the recipient's, the finalised guidelines aim to remove a barrier that the agency and commenters described as long-standing [s1]. The dollar reimbursement cap of $6,000 per organ donated is unchanged; what has changed is who qualifies and in what order [s1].

Sources

• [s1] Modification of Living Organ Donation Reimbursement Program Eligibility Guidelines in Response to Honor Our Living Donors Act — Health Resources and Services Administration / Federal Register, 29 September 2026.
• [s2] Modification of Living Organ Donation Reimbursement Program Eligibility Guidelines in Response to Honor Our Living Donors Act (proposed; request for comment) — Health Resources and Services Administration / Federal Register, 1 July 2026.