Cancer is the second leading cause of death in the U.S., claiming over 600,000 lives annually, according to the CDC. This brings up an important question: How does Medicare cover cancer treatment?
In this article, we summarize Medicare coverage for cancer to give you a comprehensive understanding of the topic and help you make informed decisions.
Understanding Medicare Coverage for Cancer Treatment
Navigating cancer treatment can be daunting, both emotionally and financially. Fortunately, those enrolled in Medicare will have many of the costs taken care of.
Medicare provides coverage for a wide range of diagnostic and treatment procedures essential in cancer care. They include:
- Diagnostic Procedures: These include colonoscopies, mammograms, X-rays, biopsies, and blood tests.
- Treatment Options: Post diagnosis of cancer, physicians often recommend a multidisciplinary treatment approach. Medicare coverage extends to:
- Surgery, aimed at excising malignant tumors to halt the spread of cancer cells.
- Radiation therapy, which uses high-energy particles to shrink and eliminate tumors.
- Chemotherapy, which utilizes potent chemicals to target and eradicate cancer cells.
- Immunotherapy, a treatment method designed to fortify the immune system’s response against cancer.
Cancer coverage under Medicare consists of many distinct parts:
- Original Medicare (Part A and Part B): Part A (Hospital Insurance) covers inpatient hospital stays, providing patients with financial support during any prolonged hospitalizations related to their cancer care. Part B (Medical Insurance) covers outpatient services, preventative care, and consultations.
- Medicare Advantage (Part C): Private insurance companies offer Part C plans as an alternative to Original Medicare. Federal law requires Medicare Advantage plans to provide at least all benefits of Original Medicare, with the flexibility of bundling together optional benefits like dental, vision, and hearing services.
- Medicare Part D (Prescription Drugs): Part D caters to the pharmaceutical needs of cancer patients. It covers specific cancer drugs and other essential prescription medications. For those under Original Medicare, a separate enrollment into a standalone Part D plan is necessary for prescription drug coverage.
Medicare Part A and Cancer Treatment
Medicare Part A provides vital care for cancer patients, covering a variety of treatment-related expenses. They include:
- Inpatient hospital stays: Covers cancer treatments received during hospitalization.
- Cancer surgeries: Covers all costs from doctor’s fees to post-operative care such as blood transfusions and reconstructive surgery.
- Chemotherapy during hospitalization: Part A covers the cost of hospital-based chemotherapy if a physician mandates it.
- Radiation during hospitalization: Covers the costs of inpatient radiation treatment as an inpatient.
- Skilled nursing and home health care: Part A covers skilled nursing care or home health care after a minimum three-day hospital stay.
- Hospice care: Part A covers end-of-life care for those diagnosed with terminal cancer.
Medicare Part B and Cancer Treatment
Medicare Part B offers comprehensive coverage for outpatient cancer care to address a range of vital services and treatments. They include:
- Doctor’s visits: Regular check-ups, monitoring, and post-operative consultations.
- Diagnostic tests: Essential tests such as X-rays and CT scans to facilitate early detection and effective treatment.
- Preventive and screening services: Part B covers screenings and preventive services for individuals at risk.
- Chemotherapy: Both intravenous and oral chemotherapy treatments administered in outpatient clinics or doctor’s offices are covered by Part B.
- Radiation therapy: Part B covers radiation therapy received at outpatient clinics or Medicare-approved facilities.
- Immunotherapy: Outpatient immunotherapy, whether received in a doctor’s office or a freestanding clinic, comes under Part B coverage. Immunotherapy vaccines deemed medically necessary might be part of Medicare Part D.
- Durable Medical Equipment (DME): Equipment like wheelchairs, walkers, feeding pumps, and enteral nutrition equipment prescribed for home use are also covered.
- Mental health services: Part B covers cancer-related mental health services, both in clinics and hospital outpatient departments.
- Nutritional counseling: This is available for patients with related complications like diabetes or kidney disease.
- Clinical research studies: If you’re considering participating in a clinical trial, Part B may cover a substantial portion of the costs.
Note, for many treatments under Part B, Medicare typically covers 80% of the approved amount, with the patient responsible for the remaining 20% after meeting the Part B deductible.
Medicare Part C (Medicare Advantage) and Cancer Treatment
Medicare Part C is mandatorily required to offer all the benefits that Original Medicare (Part A and Part B) provides. In terms of cancer treatment, this means that Part C should cover essential services such as inpatient and outpatient treatments, chemotherapy, radiation, and surgeries just like Part A and Part B.
Many Medicare Advantage plans offer extra benefits not typically covered by Original Medicare, such as prescription drug coverage (Part D), dental, vision, and hearing services. However, coverage may vary depending on the specific plan you choose and whether the healthcare providers are in-network for your Medicare Advantage Plan.
Examine your plan details carefully and check with your healthcare provider to make sure they accept Medicare.
Medicare Part D (Prescription Drug Coverage) and Cancer Treatment
Medicare Part D offers comprehensive coverage for various prescription drugs integral to cancer treatment. That includes oral chemotherapy drugs, anti-nausea medications, and pain relievers, among others. Part D may also cover immunotherapy vaccines when deemed medically necessary.
Although many Medicare Advantage plans cover prescription drugs, this list of drugs might differ among plans. Review your plan’s formulary to make sure it covers your required medications.
Advance Beneficiary Notice (ABN) and Cancer Treatment
Cancer patients under Medicare often navigate complex treatments that come with varying coverage rules. The Advance Beneficiary Notice (ABN) is an important consideration in this regard.
ABNs are official notifications provided to beneficiaries by healthcare providers when there’s doubt about Medicare coverage for a specific treatment or service. In the context of cancer, it might relate to new therapies, certain diagnostic tests, or experimental treatments.
Providers may anticipate Medicare declining coverage for a service or treatment if it is “not medically necessary” or “likely not covered.”
The purpose of the ABN is to shield beneficiaries from unexpected out-of-pocket expenses. While they indicate potential non-coverage, they do not mean certain denial. Cancer patients can still opt for treatment and appeal to Medicare if they are denied coverage.
Reach out to CoverRight for further information about cancer care coverage under Medicare. We’re your go-to platform for comprehensive Medicare guidance tailored to your needs.
Frequently Asked Questions
Does Medicare cover all types of cancer treatment?
While Medicare does cover a wide range of cancer treatments, it might not cover every single type. Medicare covers medically necessary treatments such as surgeries, radiation, chemotherapy, and immunotherapy. Make sure to review the specifics of your Medicare plan or consult with a Medicare specialist to determine the exact treatments the plan covers.
Does Medicare cover experimental or clinical trial treatments?
Medicare Part B may cover certain costs related to clinical research studies and trials. Generally speaking, Medicare is unlikely to cover experimental treatments that are not widely recognized in the medical community.
What if my cancer treatment requires long-term hospital stays?
Medicare Part A (Hospital Insurance) provides coverage for inpatient hospital stays. This can assist in alleviating the financial burden of prolonged hospitalizations related to cancer care. There are, however, limits to the duration of coverage and associated costs.
Will Medicare cover the costs of cancer-related screenings and preventive services?
Yes, Medicare Part B covers specific cancer screenings and preventive services. This can include mammograms, colonoscopies, and other early detection tests. It’s a good idea to check which screenings your plan covers and if there are any associated out-of-pocket costs.
Can I appeal if Medicare denies coverage for cancer treatment?
Yes! You have the right to file an appeal if Medicare denies coverage for a particular cancer treatment. Keep all documentation related to the treatment in question and work closely with your healthcare provider to gather necessary evidence supporting the need for the procedure.