Does Medicare Cover Cancer Treatment? – Explaining the Benefits and Coverage

does medicare cover cancer treatment

Aside from the mental burden, cancer treatment can often create significant financial pressure on the patients and their families. For Medicare beneficiaries, the good news is that these treatment are normally covered by the program.

We will explain the different aspects of the benefits and coverage, such as screenings and treatment options, as well as the out-of-pocket costs that may be incurred.

With a better understanding of the cancer treatment coverage of Medicare, you can help yourself or your closed one to make more informed decisions about their healthcare and financial planning.

How are Cancer Screenings Covered?

Cancer screenings are vital in the prevention and early detection of cancer. Medicare offers coverage for various preventive screenings, including breast cancer, cervical cancer, prostate cancer, lung cancer, and colorectal cancer.

Medicare covers the following preventive and screening tests: mammograms, Pap smears, pelvic exams, PSA blood tests, and low-dose computed tomography (LDCT) for lung cancer. Their frequency and coverage are determined by specific conditions and risk factors.

medicare coverage of different types of cancer treatment services

Medicare Coverage of Different Types of Cancer Treatment Services

1. Surgery

Involves the removal of cancerous tumors or masses, with the goal of ridding the body of the cancerous cells completely. Surgery is often used for solid tumors that are localized and haven’t spread to other parts of the body.

Medicare Coverage for Cancer Surgery Treatment

Medicare’s coverage for surgery and most cancer treatments is provided through both Medicare Part A (hospital insurance) and Part B (outpatient medical care).

If you are admitted to the hospital for inpatient surgery to remove a tumor or treat cancer, Medicare Part A will generally cover the costs associated with the surgery. These costs may include the fees for the surgeon, anesthesiologist, operating room, prescription medications administered during your stay, and any necessary hospital stays.

Part B, on the other hand, covers medically necessary outpatient care. For cancer services, the coverage for surgery treatments under Part B may include consultations with surgeons, second opinions, and outpatient surgical procedures performed in an outpatient clinic or a doctor’s office, such as oral chemotherapy outpatient surgery.

It is important to note the different coverage rules and cost-sharing requirements between Part A and Part B: For the former, there is a deductible for each benefit period and, based on the length of the hospital stay, there may be additional cost. Part B has coinsurance, which means that you are required to pay 20% of the Medicare-approved amount for outpatient surgeries and related services.

2. Radiation Therapy

High-energy radiation can be used to kill cancer cells and shrink tumors by damaging the DNA of these cells, thereby preventing the cells from multiplying and causing more harm to the body. It is administered externally (external beam radiation) or internally (brachytherapy) depending on the type and location of the cancer.

Medicare Coverage for Radiation Therapy

Just like surgery, radiation therapy is another popular and important cancer treatment that Medicare provides coverage for. The treatment may be covered by either Part A or Part B, depending on whether it is classified as inpatient or outpatient.

If the therapy is done for a hospital inpatient or at a skilled nursing facility, Part A will cover the individual responsible for the deductible and coinsurance. Therapy conducted at outpatients or patients of freestanding clinics, it is covered by Part B, with beneficiaries responsible for 20% cost sharing and the Part B deductible.

3. Chemotherapy

Chemotherapy refers to the use of medications (chemo drugs) to target and kill rapidly dividing cells, including cancer cells. They can be administered intravenously or orally. This method is normally used when the cancer has spread throughout the body.

Medicare Coverage for Chemotherapy

Chemotherapy is another common treatment option for cancer patients. The coverage for these treatments under Medicare depends on the specific circumstances and treatment settings of cancer patients.

Part A Coverage for In-Patient Chemotherapy

Part A covers chemotherapy for hospital inpatients. But if the chemotherapy is administered in a hospital outpatient setting, doctor’s office, or freestanding clinic, Medicare Part B will provide coverage. Note that the location where chemotherapy is administered can affect the costs. In a hospital outpatient setting, copayments may apply, while in other settings, you will be required to pay for the 20% cost sharing along with the Part B deductible.

Part D Coverage for Out-Patient Chemotherapy

Medicare Part D, also known as Medicare drug coverage, may also cover certain chemotherapy treatments and related prescription drugs, including anti-nausea medications, oral chemotherapy drugs, pain medications, and other drugs necessary for cancer treatment.

Additionally, Medicare drug coverage options can help individuals manage the costs associated with oral prescription drugs used with chemotherapy.

4. Immunotherapy

Immunotherapy seeks to stimulate the immune response and help the body recognize and attack cancer cells. It involves the use of substances such as immune checkpoint inhibitors and monoclonal antibodies.

Medicare Coverage for Immunotherapy

Medicare Part B, which covers medically necessary outpatient services, provides coverage for immunotherapy for individuals who are deemed medically necessary for the treatment of cancer.

The coverage for this type of therapy may depend on factors such as the specific type of cancer being treated, the stage of cancer, and the specific immunotherapy drug being used. Medicare will generally provide coverage for immunotherapy drugs approved by the U.S. Food and Drug Administration (FDA) and considered medically necessary for the treatment of cancer.

5. Targeted Therapy

Targeted therapy refers to the use of drugs to block or inhibit certain targeted molecules or genes in cancer cells that are involved in their growth and survival. The aim is to disrupt the growth and spread of cancer cells while minimizing damage to healthy cells.

Medicare Coverage for Targeted Therapy

Similar to immunotherapy drugs, Medicare Part B typically provides coverage for targeted therapy drugs when they are deemed medically necessary for the treatment of cancer. Medicare will generally cover targeted therapy cancer drugs only that are approved by the U.S. Food and Drug Administration (FDA) and considered appropriate for the individual’s specific type of cancer.

Note that coverage are determined on a case-by-case basis, with factors such as medical necessity and evidence-based guidelines being taken into consideration.

6. Hormone Therapy

Hormone therapy uses medication to treat cancers that are hormone-sensitive, such as breast and prostate cancers. These medications either block the production of hormones or interfere with their action, thereby slowing down or stopping the growth of hormone-dependent cancer cells.

Medicare Coverage for Hormone Treatment

As with immunotherapy and targeted therapy, hormone cancer treatment is covered by Medicare in some cases. Medicare Part B generally provides coverage for hormone therapy drugs and procedures that are considered medically necessary and prescribed by a healthcare provider.

understanding your financial responsibilities for cancer treatments

Understanding Your Financial Responsibilities for Cancer Treatments

Most of the cancer treatments we listed above can be used on their own or in combination with other treatments depending on the type and stage of cancer. The Medicare coverage for these treatments is determined by the specific guidelines and eligibility criteria associated with each part of Medicare.

Remember, Original Medicare (Part A, B, and D) has a 20% co-insurance and no limit on max out-of-pocket. With most cancer treatments typically costing between $10,000 to $200,000, you could be facing a huge financial burden.

How Medigap Plans Can Help Offset the Cost of Cancer Treatments

Cancer treatments can be overwhelmingly expensive, involving a range of services and procedures that may quickly lead to substantial out-of-pocket expenses. For individuals with Original Medicare, which covers many cancer-related services, the additional coverage provided by Medigap plans can be instrumental in managing these financial burdens. Here’s how Medigap can help:

Coverage of Copayments, Coinsurance, and Deductibles

Original Medicare typically covers a significant portion of approved cancer treatments, which includes chemotherapy, radiation, surgeries, and some prescription drugs administered in a hospital or clinic setting under Part B. However, patients are still responsible for coinsurance, copayments, and deductibles, which can be substantial. Medigap plans specifically help cover these costs:

  • Part A Deductible and Coinsurance: For hospital stays, which are common for cancer treatment, Medicare Part A requires a deductible and coinsurance if the stay exceeds 60 days. Medigap plans can cover these costs, ensuring that long-term hospitalization does not become a financial strain.

  • Part B Coinsurance and Copayments: Typically, Medicare Part B covers 80% of the costs of outpatient care, including doctor visits and chemotherapy administered in a non-hospital setting. Medigap plans can cover the remaining 20%, alleviating the financial impact of ongoing outpatient treatments.

Do Medicare Advantage Plans Provide Health Insurance Coverage for Cancer?

So while it is important for patients to consult with their insurance providers and understand their Medicare coverage about cancer treatment before making any decision, there’s one other option they can consider.

Medicare Advantage plans, also known as Medicare Part C, offer an alternative way for beneficiaries to receive Medicare benefits. While these plans are required to provide at least the same coverage as Original Medicare (Parts A and B), there’s one significant difference: the different plan options offer different premiums and yearly maximum out-of-pocket amounts (MOOP). And once MOOP is reached, the plan pays 100%.

Additionally, some plans may even offer additional benefits not covered by Original Medicare. There are also special Medicare Plans (DSNPs for those on Medicaid) or CSNPs (for individuals suffering from chronic conditions).

speak with a professional to learn more about treatment options

Speak with a Professional to Learn More About Treatment Options

Receiving a cancer diagnosis is challenging both emotionally and financially. But just remember that there are many ways where you can enhance your access to cancer treatment options. From preventative screenings to various treatment options, Medicare offers coverage choices to suit your financial situation.

If you are looking for more comprehensive coverage for cancer treatment that comes with Medicare Advantage Plans or Medigap Plans, one way is to speak with a broker or licensed agent.

Engaging with a professional can help you understand coverage specifics, such as out-of-pocket costs and potential limitations. It will allow you to make informed decisions about healthcare and your financial well-being. By having a clear understanding of your plan’s coverage for cancer treatment, Medicare beneficiaries can navigate the complex landscape of cancer care with confidence and peace of mind.

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