If you have received a cancer diagnosis, you may be concerned about which cancer treatments, supplies, services, and prescription drugs Medicare covers. Take a breath and relax, because the most common treatments, services, and medications are covered. In this MedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. article, we’ll explain how Medicare covers cancer treatment.
- Cancer is a disease that causes your cells to mutate uncontrollably, which inhibits their ability to function properly.
- Medicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. will cover cancer treatments and services while you are admitted to an inpatient facility.
- Medicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. provides coverage for your outpatient cancer treatments, services, medical supplies, and certain medications.
- Medicare covers many different forms of cancer treatment, such as chemotherapy, tumor excisions, and radiation therapy.
- Medicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. will help with the costs of certain services that Medicare does not cover.
- Medicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... plans will cover most of your prescription drug needs for cancer treatments.
- A Medicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will cover the same services as Part A and Part B, but it may limit their services to Doctors, hospitals, pharmacies, and other healthcare providers that agree to health plan members' services and supplies at a set price are in-network providers. With some health plans, your care is only covered if you get... providers.
- Medigap policies can help with the Out-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. for cancer treatments after Medicare has provided coverage.
What Is Cancer?
Cancer is a genetic disease that causes your body’s cells to rapidly divide and infect other cells around them, forming abnormal lumps of cancerous tissue called tumors. Cancerous cells can spread infect tissues in organs throughout the body, causing them to fail in their function and be unable to fight off otherwise simple infections. Symptoms that can indicate the presence of cancer include:1Mayoclinic.org, “Cancer: Symptoms & Causes“, Accessed December 6, 2021
- Lump or area of thickening that can be felt under the skin
- Weight changes, including unintended loss or gain
- Skin changes, such as yellowing, darkening or redness of the skin, sores that won’t heal, or changes to existing moles
- Changes in bowel or bladder habits
- Persistent cough or trouble breathing
- Difficulty swallowing
- Persistent indigestion or discomfort after eating
- Persistent, unexplained muscle or joint pain
- Persistent, unexplained fevers or night sweats
- Unexplained bleeding or bruising
If you are diagnosed with cancer, the doctor will determine how far it has progressed from level 0 to level 4, with 4 being the most advanced cancer stage. Different levels of cancer will require different treatments. Fortunately, Medicare covers most of the well-known methods of cancer treatment.2Mayoclinic.org, “Cancer: Diagnosis & Treatment“, Accessed December 6, 2021
How Does Medicare Cover Cancer Treatments?
Original Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. (Part A and Part B) covers cancer treatments for its beneficiaries. However, each part covers different kinds of treatment. Listed below are the cancer treatment services that are covered by Medicare Part A and Part B.
- Inpatient hospital stays, including cancer treatments you get while you’re an inpatient in the hospital.
- Skilled nursing facility care (following a 3-day related hospital stay).
- Health care services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered... (like rehabilitation services for physical therapy, speech-language pathology therapy, occupational therapy, or skilled nursing care).
- Hospice is a special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. care.
- Some costs of clinical research studies while you’re an inpatient in the hospital.
- Surgically implanted breast prostheses after a mastectomy if the surgery takes place in an inpatient setting.
- Doctors’ visits.
- Chemotherapy drugs administered through the vein in an outpatient clinic or a doctor’s office.
- Some oral chemotherapy treatments.
- Radiation treatments given in an outpatient clinic.
- Diagnostic tests like X-rays and CT scans.
- Durable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds. (DME) like wheelchairs and walkers.
- Outpatient surgeries.
- Mental health services, including services that are usually provided outside a hospital (like in a clinic, doctor’s office, or therapist’s office) and services provided in a hospital’s outpatient department.
- Nutritional counseling if you have diabetes or kidney disease.
- Certain preventive and screening services.
- Enteral nutrition equipment (feeding pump) as DME that your doctor prescribes for use in your home, and certain nutrients if you can’t absorb nutrition through your intestinal tract or you can’t take food by mouth.
- Some costs of clinical research studies while you’re an outpatient.
- Breast prostheses (external breast prostheses, including a post-surgical bra) after a mastectomy. Part B covers surgically implanted breast prostheses after a mastectomy if the surgery takes place in an outpatient setting.
- In some cases, a second opinion for surgery that isn’t an emergency, and a third opinion if the first and second opinions are different.
A copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service., Coinsurance is a percentage of the total you are required to pay for a medical service. , or A deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share. may apply for each service. To find out how they charge for a specific test, item, or service, speak with your health care providers.3Medicare.gov, “Medicare Coverage of Cancer Treatment Services“, Accessed December 6, 2021
Does Medicare Cover Chemotherapy?
Both Medicare Part A and Part B will cover chemotherapy treatment. If you are an inpatient, Part A covers your chemotherapy. However, if you receive chemotherapy in an outpatient setting, it’s covered by Part B.4Medicare.gov, “Chemotherapy“, Accessed December 6, 2021
If you get your chemotherapy treatment in an outpatient clinic or your doctor’s office, you pay a copayment, and Medicare Part B picks up the rest. However, if your chemotherapy treatment is given in a hospital outpatient clinic, you pay a 20 percent copayment instead.4Medicare.gov, “Chemotherapy“, Accessed December 6, 2021 If you have a Medicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. policy that covers the Part B coinsurance, it will pay your out-of-pocket costs.
Does Medicare Cover Other Cancer Treatments?
Absolutely. Medicare covers the following treatments if your doctor considers them Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. for your condition:
- Genetic therapy that uses gene-modified cells to attack cancer cells5CMS.gov, “Chimeric Antigen Receptor (CAR) T-cell Therapy“, Accessed December 6, 2021.
- Hormone therapy to treat hormonal-based cancers, such as breast cancer and prostate cancer6Medicare.gov, “A patient-focused approach to oncology care“, Accessed December 6, 2021.
- Immunotherapy drugs that boost the body’s immune system to eliminate cancer cells7CMS.gov, “Autologous Cellular Immunotherapy Treatment“, Accessed December 6, 2021.
- Radiation therapy to eliminate cancer cells8Medicare.gov, “Radiation therapy“, Accessed December 6, 2021.
- Surgery for removing cancerous tumors, also known as an excision9Medicare.gov, “Surgery“, Accessed December 6, 2021.
Do Medicare Advantage Plans Cover Cancer Treatment?
Medicare Advantage plans are an all-in-one alternative to Original Medicare. These bundled plans include Part A, Part B, and usually Part D. If you’re in a Medicare Advantage plan your plan must give you at least the same coverage as Original Medicare, but it may have different rules and costs. Specifically, most plans require you to get a referral to see a specialist, such as an oncologist. And, what you pay out-of-pocket for both inpatient and outpatient treatment will be different.12Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 6, 2021
What Doesn’t Medicare Cover for Cancer Treatments?
While Medicare provides coverage for many cancer treatments and services, it does not cover everything. Here are some services that are not covered by Medicare Part A or Part B:3Medicare.gov, “Medicare Coverage of Cancer Treatment Services“, Accessed December 6, 2021
- Room and board in assisted living facilities.
- Adult daycare.
- Long-term nursing home care.
- Medical food or nutritional supplements (except enteral nutrition equipment).
- Services that help you with activities of daily living (like bathing and eating) that don’t require skilled care.
Does Medicare Cover Cancer Treatment Medications?
A Medicare Part D plan will cover most of your prescription drugs that aren’t covered by Part B, such as anti-nausea drugs and pain medication while undergoing chemotherapy. When selecting a Part D plan in your area, it will be important to check the plan’s A formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered. to see the cost of your chemotherapy drugs with that plan. Depending on the Part D plan, members may pay an annual deductible, before the plan begins paying its share, as well as a copayment11Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 6, 2021.
Cancer can be a devastating disease, not only for your health but also for your funds. Fortunately, Medicare can help cushion the financial impact while you receive the treatments and services you need. Consult with your doctor, they will let you know where your condition is at and help you find the best treatment option for the best price with Medicare.
If you have additional questions about what Medicare will cover for your cancer treatment, you can speak with a Medicare professional at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
- 1Mayoclinic.org, “Cancer: Symptoms & Causes“, Accessed December 6, 2021
- 2Mayoclinic.org, “Cancer: Diagnosis & Treatment“, Accessed December 6, 2021
- 3Medicare.gov, “Medicare Coverage of Cancer Treatment Services“, Accessed December 6, 2021
- 4Medicare.gov, “Chemotherapy“, Accessed December 6, 2021
- 5CMS.gov, “Chimeric Antigen Receptor (CAR) T-cell Therapy“, Accessed December 6, 2021
- 6Medicare.gov, “A patient-focused approach to oncology care“, Accessed December 6, 2021
- 7CMS.gov, “Autologous Cellular Immunotherapy Treatment“, Accessed December 6, 2021
- 8Medicare.gov, “Radiation therapy“, Accessed December 6, 2021
- 9Medicare.gov, “Surgery“, Accessed December 6, 2021
- 12Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 6, 2021
- 10Medicaid.gov, “Nursing Facilities“, Accessed December 6, 2021
- 11Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 6, 2021