According to the American Cancer Society, approximately 39.5% of Americans will be diagnosed with cancer at some point in their life.
Treatments can be costly. The good news is that Medicare Parts A, B, and D will cover different aspects of your treatment plan. Medicare Advantage Plans (Part C) also provide coverage but are not as comprehensive as Original Medicare combined with a Medicare Supplement.
Today we will talk about what options you have.
Keep reading to learn more.
Part A Cancer Coverage (Hospital Insurance)
Medicare Part A provides coverage for hospital inpatient care.
This includes skilled nursing care, hospice, and home health care. Part A covers anything major that requires you to be admitted to a hospital for treatment.
Part A is available to all legal residents of the United States. Turning 65 or getting approved for disability are the most common ways to qualify.
Take a look at what Part A will cover when it comes to cancer:
- Any cancer treatments received while you’re an inpatient at the hospital. If you’re unsure of your status ask the hospital staff.
- Home health care (rehab services for physical therapy, skilled nursing care, occupational therapy, speech-language pathology).
- Hospice care.
- Skilled nursing care (has to be following a 3-day hospital stay).
- Breast implants after a mastectomy if surgery is in an inpatient setting.
Let’s break it down further.
Chemotherapy and Part A
Patients who receive chemotherapy treatment in a hospital, outpatient facility, or doctor’s office are covered by Medicare.
If it’s received while you’re in the hospital (aka inpatient), you might have to pay the Part A deductible and coinsurance if applicable.
The amount of chemotherapy covered by Medicare is determined by the type of treatment you’re receiving. Your doctor will be able to look it up for you.
By enrolling in a Medigap plan, you can avoid having to pay this. Keep reading, we’ll talk more about Medigap plans below.
Does Medicare Pay for Chemotherapy in a Skilled Nursing Facility?
Yes, Medicare will cover up to 100 days of skilled nursing facility care (per benefit period). Anything beyond 100 days is considered an out-of-pocket expense for the beneficiary.
Radiation and Part A
Part A provides coverage for inpatient care.
Radiation treatment received during a hospital stay is covered under Part A.
It will also cover costs for any medications needed during your hospital stay, as well as meals you have while in the hospital.
Part B Cancer Coverage (Medical Insurance)
Remember, Part B of Medicare covers outpatient medical treatments such as:
- Visits to the doctor
- Screenings that are both routine and preventative
- Wellness visits scheduled once a year.
- Diagnostic testing in the lab
- Visits to the emergency room
- Specialist consultations
- Medical equipment and supplies
Part B is available to all legal residents if they meet the necessary eligibility requirements. You must be eligible for Part A to qualify for Part B.
Turning 65 or losing group medical coverage when retiring are some of the most common ways to qualify for Part B.
Take a look at what Part B will cover when it comes to cancer:
- Outpatient surgeries.
- Doctor’s visits.
- If you have diabetes or kidney disease, nutritional counseling.
- Some oral chemo treatments.
- Radiation received in an outpatient setting.
- Diagnostic tests such as X-Rays and CT Scans.
- Durable Medical Equipment (DME).
- Some preventative and screening services.
- Mental health services that are provided outside of a hospital (like a clinic, therapist’s office, or doctor’s office). Services provided in the hospital’s outpatient department are also covered.
- Enteral nutrition equipment (aka feeding pump) that is prescribed for use in the home.
- Some costs of clinical research studies.
- External breast prostheses (post-surgical bras).
- Surgically implanted breasts after a mastectomy, if the surgery takes place in outpatient.
- In special circumstances, a second opinion for non-emergency surgery, and a third opinion if the first and second differ.
Let’s go further.
Chemotherapy and Part B
Patients who receive chemotherapy treatment in a hospital, outpatient facility, or doctor’s office are covered by Medicare.
Cancer screenings and treatments at a doctor’s office or clinic are covered by Part B. Some cancer screenings are covered in full by these preventive care programs.
In addition, Part B covers 80% of the cost of chemotherapy treatments performed as an outpatient or in a doctor’s office.
The amount of chemotherapy covered by Medicare is determined by the type of treatment you’re receiving.
By enrolling in a Medigap plan, you can avoid having to pay anything not covered by Original Medicare. We’ll talk more about this later.
Radiation and Part B
Remember, Part B covers outpatient services. Radiation received in a doctor’s office or clinic would be covered under Part B.
Any medications to manage side effects (anti-nausea, pain relievers), when given by a healthcare provider in an outpatient setting will also be covered under Part B.
Keep in mind, Part B does not cover everything. In most cases, it pays 80% of your medical bills after you meet a deductible.
It is essential to know how Part B works with Part A to cover some healthcare costs. Understanding what is covered and considering a Medicare Supplement can minimize out-of-pocket exposure.
Part C Cancer Coverage (Medicare Advantage Plans)
Medicare Advantage plans are often called Part C of Medicare.
These are plans sold by private insurance companies approved by Medicare. They will cover the cost of most of your Part A (hospital) and Part B (medical) services.
They help pay for things like major hospital stays, doctor’s visits, preventative care, lab work, meal delivery services, and dental.
Some plans offer additional coverage normally not available with traditional Medicare that helps lower out-of-pocket medical expenses (like dental and eye care).
Although they are managed by Medicare, coverage is through private insurance companies.
You’ll need to make sure your doctor, hospital, and pharmacy are covered by the plan you are considering.
Part D Cancer Coverage (Prescription Drug Plans)
Everyone with Medicare has access to prescription drug coverage.
Keep in mind, prescription drug coverage isn’t automatically included in Medicare.
You must be enrolled in a Medicare Part D drug plan to receive coverage (or belong to a Medicare Advantage Plan with Part D coverage).
Most prescription medications, as well as some chemotherapy treatments and pharmaceuticals, are covered under Part D.
Your Part D drug plan may cover a cancer medication if your Part B does not.
It’s critical to double-check with your plan to ensure that your medications are on the formulary (a list of covered medications) and that the tier in which they are listed is correct.
This has an impact on your out-of-pocket expenses.
The following cancer-related medications may be covered under Part D:
- Chemotherapy prescriptions can only be taken by mouth.
- Anti-nausea medications
- Other prescription drugs, such as pain relievers, may be used as part of your cancer treatment.
Prescription drug coverage is available to all Medicare recipients.
Medicare Part D, however, only covers prescription medications used at home.
Keytruda is a prescription immunotherapy medication. It is administered every three weeks by infusion.
This medication must be provided by a registered medical professional. That makes it an outpatient prescription drug.
This means that, even if you have a Part D plan, your prescription medication plan is unlikely to cover Keytruda.
Keytruda will be covered in the same way as original Medicare if you are enrolled in a Medicare Advantage plan.
However, depending on the sort of plan you’re registered in, the drug’s out-of-pocket cost may differ.
Medicare Supplement (Medigap) Cancer Coverage
Medicare Supplement plans work with Medicare Part A and Part B, often referred to as Original Medicare.
In order to get a Medicare Supplement, you’ll need to make sure you have both Part A and Part B.
Original Medicare Part A and Part B cover about 80% of your medical expenses. Medicare Supplements help cover the other 20%.
They will also limit out-out-pocket expenses like deductibles, coinsurance, copays, and excess charges.
Does Medicare Cover Cancer Screenings?
As a preventive health treatment, Medicare covers 100 percent of patient-specific cancer screenings as long as your doctor accepts Medicare assignment.
- Annual mammograms for women over the age of 40.
- Pap smears and pelvic exams to screen for cervical and vaginal cancer (once every 2 years). For those at an increased risk, every year.
- Colorectal cancer screenings, including colonoscopies (every 10 years for those over 50). Annual screenings for those at an increased risk.
- Annual lung screenings for smokers or former smokers (55-77) whose doctor orders a screening.
- Prostate cancer screening (annually) for men over 50.
Let’s break it down.
What Screenings Are Covered?
In regards to breast cancer, Medicare covers two different types of mammograms:
- If your doctor accepts Medicare assignment, you can get a screening mammogram once every 12 months at no cost. Must be over the age of 40.
- If medically necessary, a diagnostic mammogram. The frequency will depend on your own situation. This type of mammogram will be covered by Medicare for 80% of the cost, while you will be liable for the remaining 20% as well as the Part B deductible.
For cervical cancer, Medicare covers the following services:
- A Pap smear
- A Pelvic Exam (and breast exam)
These are covered every 24 months for most women and every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of childbearing age and have had an abnormal Pap Smear in the preceding 36 months.
For prostate cancer, Medicare covers the following screenings once every 12 months (for men over 50):
- PSA (prostate-specific antigen) blood tests
- DRE (digital rectal exams)
If you receive a PSA test from a doctor who accepts Medicare assignments, you won’t have to pay anything. If the doctor doesn’t, you might have to pay. You will be responsible for 20% of the Medicare-approved price for the exam and your physician’s services if you have a DRE. The Part B deductible is also your responsibility. If the evaluation is performed in a hospital outpatient setting, a copayment will be required.
For lung cancer, Medicare Part B will cover the following screenings:
- A Low-Dose Computed Tomography (LDCT) if all of the following conditions are met:
- You’ve reached the age of 55.
- Your doctor issues you a written order.
- You’re either a current smoker or a former smoker who has quit within the last 15 years.
- For the past 30 years, you have smoked an average of one pack or 20 cigarettes every day.
- You don’t have any signs or symptoms of lung cancer.
For colorectal cancer, Medicare covers a traditional screening colonoscopy and other preventative tests including:
- A colonoscopy every 10 years (for most). If you’re at high risk for colon cancer, you should have one every 24 months.
- If you’re 50 or older and your doctor accepts Medicare, you’re entitled to a free fecal occult blood test (FOBT) once a year.
- If you’re 50 or older and at high risk for colorectal cancer, you should get a screening barium enema every 24 months, or every 48 months if this test is done instead of a flexible sigmoidoscopy or standard colonoscopy.
- If you’re 50 to 85 years old, have no signs of colorectal disease, and are at average risk for colorectal cancer, you should obtain a multi-target stool DNA lab test every three years.
Does Medicare Cover Wigs?
Due to the fact that chemotherapy causes hair loss, many cancer patients opt to wear a wig.
Wigs, unfortunately, are not covered by Original Medicare or Medigap. They may be covered by some Medicare Advantage policies or cancer insurance plans.
Keep in mind, Medicare Advantage plans are managed by private insurance firms. These plans must cover at least the same services as Original Medicare, according to Medicare criteria.
It is important to remember that the additional coverage provided by Medicare Advantage plans varies from plan to plan. As a result, some insurance plans may cover wigs while others may not.
A doctor’s prescription for a wig may be required by some Medicare Advantage plans. You may be required to purchase a wig first and then file a claim to your plan provider for reimbursement, depending on the plan’s requirements. Some wig insurance policies may even include a cap on how much they would pay for wigs.
Individuals with a Medicare Advantage plan can inquire about their coverage by contacting their plan’s provider.
A cancer insurance policy is one that pays out a lump amount if the policyholder is diagnosed with the disease.
The payouts on these plans typically vary from $5,000 to $200,000 (plans with higher payouts have higher premiums).
Cancer insurance policies are similar to critical illness insurance plans, however, they only cover cancer diagnoses rather than the broader range of ailments covered by critical illness insurance.
Cancer insurance isn’t meant to be a stand-alone policy. Rather, it’s meant to be used in conjunction with a typical major medical health insurance plan.
It is usually a good idea to have some kind of additional cancer coverage to cover expenses that are related to having cancer outside of traditional medical bills.
The money from the cancer insurance policy can be used to cover out-of-pocket expenditures under the main medical plan, as well as any costs associated with cancer treatment, such as lost income and transport to treatment facilities.
You already know that cancer treatments can be costly.
The good news is that Medicare Parts A, B, and D will cover different aspects of your treatment plan.
It is essential to know how Part B works with Part A to cover your healthcare costs. Understanding what is covered and considering a Medicare Supplement can minimize out-of-pocket exposure.
As you’ve also learned, Medicare Advantage Plans (Part C) provide coverage but are not as comprehensive as Original Medicare plus a Medicare Supplement. When choosing Medicare Advantage Plan, make sure your doctor, hospital, and pharmacy are covered.
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