Does Medicare cover cancer treatment?

Creator: SingleCare
Published: 2022-09-16T23:52:08-04:00

Learn which cancer treatments are covered by Medicare and how to save

By Lindsay Malzone | Updated on Jan. 19, 2024 Medically reviewed by Scott Dershowitz, LMSW, CMC

More than 20 million Medicare beneficiaries are cancer patients or survivors, and in 2017, 1.2 million Medicare beneficiaries filled a prescription for a cancer drug. The different parts of Medicare work to provide cancer coverage in a variety of settings and for different treatment modalities.

Medicare cancer coverage

Medicare Part A covers the care you receive in a hospital inpatient setting. If you’re being treated at an outpatient facility or health care provider’s office, coverage will fall under Medicare Part B. Part B covers 80% of services and treatments received at an outpatient facility, such as diagnostic imaging, outpatient surgery, chemotherapy, radiation, and injectable medications.

There are several ways to receive your Medicare insurance, and you should evaluate your options for coverage and price. For some people with cancer, Original Medicare plus a Medicare Part D Plan may be a good option. You may also want to consider secondary coverage with a Medigap plan. Additionally, you may want to consider a Special Needs Plan designed specifically for people with cancer.

If you choose to enroll in a Medicare Advantage plan (Part C) instead, you’ll more than likely reach your maximum out-of-pocket (MOOP) limit for cancer treatment due to cost-sharing. If you meet your MOOP, you will no longer owe cost-sharing for covered Part A and Part B services, and those services will be paid for by Medicare.

What’s covered

Part A covers:

Inpatient hospital stays, including cancer treatments you get while you’re an inpatient in the hospital
Skilled nursing facility care
Home health care (like rehabilitation services for physical therapy, speech-language pathology therapy, occupational therapy, or skilled nursing care)
Any blood transfusions
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
Hospice care

Part B covers:

Healthcare provider visits
Many chemotherapies and cancer drugs are administered through your vein in an outpatient clinic or a healthcare provider’s office
Some oral chemotherapy treatments
Immunotherapy treatments
Radiation treatments in an outpatient clinic
Diagnostic tests (like X-rays and CT scans)
Durable medical equipment (DME) (like wheelchairs and walkers)
Enteral nutrition equipment (feeding pump) as DME that your healthcare provider prescribes for use in your home
Outpatient surgeries
Breast prostheses (external breast prostheses, including a post-surgical bra) after a mastectomy
Mental health services, including services that you usually get outside a hospital (like in a clinic, healthcare provider’s office, or therapist’s office) and services you get in a hospital’s outpatient department
Nutritional counseling if you have diabetes or kidney disease
Certain preventive and screening services like Pap tests and colorectal cancer screenings
Some costs of clinical research studies while you’re an outpatient

Part C covers:

Part C is also known as Medicare Advantage. With a Medicare Advantage plan, your benefits are regulated by the federal government. This means that the Medicare Advantage plan must cover the same services Part A and Part B cover. The difference is that the private health insurance company can have different rules and costs. This means the plan may cover the same services as Part A and Part B, but the out-of-pocket costs, such as premiums, deductibles, coinsurance, and copayments, are not standardized.

Part D covers:

Prescription drugs for chemotherapy only if taken by mouth
Anti-nausea drugs
Other prescription drugs used in the course of your cancer treatment, like pain
Medication

What’s not covered

Medicare does cover the majority of cancer screenings and treatments. If your cancer screening or treatment is denied by Medicare, you have the right to appeal any decision made by Medicare if you disagree with it. You can also appeal if Medicare stops paying for any cancer screenings or treatments that you still need.

Oncologists near you who accept Medicare

The Centers for Medicare & Medicaid Services has a fantastic tool that allows you to search for healthcare providers and hospitals near you that accept Medicare. This, of course, includes oncologists. All you have to do is enter your location, select healthcare provider and clinicians or hospitals, then in the keywords area, enter oncology and select from the drop-down menu.

How much does cancer treatment cost with Medicare?

Medicare does not cover the full cost of cancer treatments. As with all coverage, there are out-of-pocket costs. A study showed that back in 2017, the average out-of-pocket costs for Medicare beneficiaries ranged between $5,976 and $8,115 after a cancer diagnosis.

Medicare Part A has a per-benefit-period deductible of $1,632 and coinsurance of $0 for the first 60 days as a hospital inpatient, $408 per day for days 61-90, and $816 per lifetime reserve day. There is a coinsurance of $204 per day for days 21-100 in a skilled nursing facility. A benefit period begins the day that you are admitted to a hospital or skilled nursing facility and ends after you have stopped receiving inpatient care for 60 consecutive days.

Medicare Part B has a monthly premium, annual deductible, and coinsurance. You’re responsible for 20% of your treatment costs with Part B. A Medigap plan can cover most, if not all, of the above-mentioned out-of-pocket costs.

With a Medicare Advantage plan, you can expect to reach the MOOP limit of $8,850 when receiving cancer treatments. Medicare Advantage also may require prior authorization, while Original Medicare does not. Some Part C plans may set the MOOP at a lower level, so it is important to consider when choosing a Part C plan.

The cost of prescription medications under a Medicare Part D plan will vary. It’s always best practice to look closely at the prescription drug plan formulary to ensure all your cancer medications will be covered.

Other ways to save on cancer treatment

Cancer treatments may be expensive, but there are ways to save. Your healthcare provider may be able to help you with financial assistance or align you with organizations that help patients with the cost of cancer treatments. Learn how else you can save on cancer treatments.

1. Medicare Extra Help

If you’re considered low-income or dual-eligible for both Medicare and Medicaid, then it’s possible that all your out-of-pocket costs for cancer medications could be covered with help from the Extra Help program under Part D.

This federal initiative reduces your out-of-pocket costs by eliminating prescription premiums as well as deductibles while also reducing copays, depending on what level of assistance you qualify for.

2. SingleCare coupons

Medicare and other medical insurance plans don’t cover the full cost of cancer medications. But there is a way for you to get those necessary prescriptions at a lower cost. SingleCare offers free coupons that can save patients as much as 80% on their medications—even if they’re covered by Medicare or another type of healthcare coverage plan.

3. Medicaid

Medicaid is a financial assistance program that helps provide affordable health coverage. If eligible for Medicaid, you may be able to receive health insurance for little to no cost. The Medicaid eligibility requirements vary from state to state, and coverage can be used in conjunction with your Medicare coverage.

4. Manufacturer rebates & coupons

Depending on your prescribed cancer medication, coupons may be available through the drug manufacturer.

5. Patient assistance programs

Some manufacturers do offer a patient assistance program. Your best option is to research online if the manufacturer offers this type of program.

6. Free samples at your doctor’s office

To save money on your prescriptions, ask for free samples at your healthcare provider’s office. Drug company representatives may leave samples at healthcare provider offices. However, this is not a long-term solution.