People who give a kidney, or part of a liver or lung, while alive can get federal help with the trip to the transplant center, the paychecks they miss and the child or elder care. Until now, whether a donor got that help turned mostly on how much the person receiving the organ earned. From September 30, it turns on the donor's own household.

The Health Resources and Services Administration, the HHS agency behind the Living Organ Donation Reimbursement Program, filed its final eligibility guidelines for public inspection on September 28. They cover "all applications reviewed on or after September 30, 2026". Mayo Clinic Arizona and the National Living Donor Assistance Center run the program for HRSA; since 2007 it has helped with over 12,000 living donations.

Why the recipient's paycheck mattered

The old rule rested on an assumption HRSA wrote down in 2020: that "recipients whose income exceeds this level will have the ability to reimburse the living organ donor". The level was 350 percent of the federal poverty guidelines. Above it, a donor qualified only if the recipient could show financial hardship.

Congress ended that in February. The Honor Our Living Donors Act says the organization paying donors "shall not give any consideration to the income of the organ recipient", as HRSA quoted the law in July. HRSA received 44 public comments on the July proposal. Thirty-four commenters explicitly backed the switch; none opposed it.

Three tiers, all open from the start

Priority Category 1: donor household income at or below 350 percent of the poverty guidelines. Highest priority.
Category 2: above 350 and up to 500 percent, "If sufficient program resources exist".
Category 3: above 500 and up to 750 percent, on the same condition, through a financial hardship waiver.

The 2026 thresholds for the 48 contiguous states and Washington, D.C.:

Household	Category 1	Category 2	Category 3
1 person	$55,860	$79,800	$119,700
2 people	$75,740	$108,200	$162,300
3 people	$95,620	$136,600	$204,900
4 people	$115,500	$165,000	$247,500

Each figure is the top of that tier. The notice prints the 500 and 750 percent lines; the 350 percent line comes from the HHS table it cites. Alaska and Hawaii run higher: for four people, the 750 percent line is $309,375 in Alaska and $284,625 in Hawaii.

In July, HRSA proposed opening Category 2 only partway through the funding period, and only if money allowed. Nine commenters objected, warning that a delay "could discourage or delay donation while a recipient's health continues to decline". HRSA changed course. At the start of each budget period, the program now "will accept and process applications from all three priority categories". That, HRSA noted, is "how the Program has de facto operated since its inception". Categories 2 and 3 can still close if money runs short, with notice "in a timely fashion prior to" closing. The notice sets no number of days.

A ceiling that did not exist before

The 2020 guidelines had a tier for "Any living organ donor, regardless of income or financial hardship, if the recipient's income is at or below 350 percent" of the poverty guidelines. The new tiers stop at 750 percent. The assistance center's site, which on September 28 still described the old rules, says: "No, there are no limits to the donor's household income".

HRSA's July estimate, from its data for September 2024 through August 2025: about 60 percent of recent applicants were at or below 350 percent, 78 percent at or below 500, and 92 percent at or below 750. By Hugin's subtraction, not HRSA's, about 14 percent of those applicants fell in the new waiver band and 8 percent above every tier.

Four commenters asked HRSA to drop income tests entirely. It declined, citing the law's preference for donors "more likely to be otherwise unable to meet such expenses": "This requirement makes it necessary to impose income eligibility parameters on applicants".

The waiver is paperwork, not a pass

For a Category 3 donor, a transplant social worker or similar staff member submits a written request attesting that the donor documented expenses large enough to bring household income down to 500 percent or below. If expenses are simply subtracted, which the notice does not spell out, a household of four in the 48 states earning $200,000 would need at least $35,000 in documented costs.

What counts: lost wages; travel, lodging and meals; child, elder or other dependent care; the household's out-of-pocket medical bills; pet care; and "Other non-discretionary household expenses (e.g., child support)". Ordinary housing, grocery and utility costs do not count. HRSA makes the final call, and "its determination will not be subject to appeal".

What the money covers

The limits did not change. Reimbursement tops out at $6,000 per donor evaluated or organ donated, for:

Travel, lodging and meals for the donor and companions, at the federal per diem rate, hotels at up to 150 percent of it. Up to five trips, three for the donor and two for companions, with more possible after complications.
Lost wages and child or elder care, up to 4 weeks around surgery and recovery, plus up to 2 weeks for complications. Tips and irregular pay count with documentation.
Follow-up visits: the same costs, within 2 calendar years of the donation.

A donor who proceeds in good faith but cannot donate, for instance because of a health finding, can be reimbursed as if the donation had happened. A non-directed donor, who gives without choosing the recipient, can apply with no named recipient. In every other case, donor and recipient must both be U.S. citizens or lawfully present, live in the U.S. or its territories, and certify compliance with the federal ban on buying and selling organs.

What to do, and when

Start with the transplant center. The assistance center "does not take applications directly from patients"; a social worker, nurse coordinator or other transplant professional submits them.
Apply before spending. Its FAQ says it "cannot reimburse expenses that were incurred before the application was approved", and approval must come before surgery.
September 30, 2026. Applications reviewed from this date follow the new rules; those reviewed earlier follow the 2020 rules. The notice keys the switch to review, not filing.
Turned down before because of a recipient's income? Ask the transplant center about reapplying. The notice does not address it.
Taxes. The FAQ says lost wage reimbursement "is income, and may be subject to federal and/or state income tax reporting". HRSA says it will consult the Treasury and the IRS on whether reimbursement can be non-taxable.
Questions: the assistance center, 888-870-5002; HRSA, livingdonorsupport@hrsa.gov.

What the record does not say

How much money there is. No budget, no forecast of whether Category 2 or 3 will close, and no date for when the current budget period began. The Act's report to Congress on donors not fully reimbursed is due by December 31, 2027.
Whether a donor above 750 percent gets anything. The guidelines still say "All persons who wish to become living organ donors are eligible" subject to funds, but no tier reaches past 750 percent, and the July proposal called that figure an income cap.
Cost of living. One poverty scale covers everywhere except Alaska and Hawaii. HRSA concedes donors in high-cost areas "may face hardship at income levels above the proposed thresholds", says it will keep evaluating, and points them to the waiver.
What the new application asks about the recipient. HRSA will still collect "limited, high-level information on recipient household income"; how is left to the operator and a future paperwork filing.
The $6,000 limit and a longer lost-wage window for liver donors. Commenters raised both; HRSA called them out of scope.