Cancer is a devastating diagnosis at any age. It can also be a deadly disease — so the right treatment can be priceless. But unfortunately, cancer treatments can also come with a high price tag. Patients diagnosed with cancer may face significant out-of-pocket costs. If you’re 65 or older and have Medicare, you may be wondering, “How much does cancer treatment cost with Medicare?” The answer is that Medicare can help subsidize the costs of cancer treatment, but it is unlikely to cover everything you need.
To best prepare yourself for how to pay for your cancer treatments with Medicare — and know how to advocate for yourself when something isn’t covered — it is important to familiarize yourself with your Medicare plan. You can also ask your doctor about how they can meet you where you’re at, both medically and financially.
[Related:How and Why to File a Medicare Appeal]
Does Medicare Cover Cancer Treatment?
Medicare covers some but not all aspects of cancer treatment. For instance, while it covers some inpatient services — like inpatient chemotherapy — for patients whose doctors have declared they have cancer, it doesn’t cover other ancillary services, such as a wig, personal care items like razors or slipper socks or a private room during hospital stays. That’s because Medicare does not deem the latter services medically necessary, even if they may feel necessary to you.
Additionally, Medicare may cover some cancer treatments and not others. For instance, your doctor may want to prescribe you a new, expensive medicine to treat your cancer, but your Medicare plan may only cover an older, less expensive version of the drug. Sometimes, getting Medicare to cover your treatments can involve working with your doctor to prescribe those that are already in your plan. Other times, it may involve getting your doctor — or your doctor’s financial team — to contact your Medicare plan or provider to request plan modifications or exceptions.
It’s important to be aware of nuances in Medicare’s coverage so you don’t wrongly assume that a specific treatment is covered — and end up with a lofty hospital bill because of it. As you read through the lists below, keep in mind that the treatments you see may not be all inclusive, and that certain brands or models of the drug of the listed treatment may be covered, and others are not.
Does Medicare cover cancer treatment after age 76?
Despite some misconceptions, Medicare does cover cancer treatment for people of all ages, including those over 76. Medicare covers most cancer treatments regardless of age.
Guide to Medicare’s Cancer Coverage: Parts A, B, C and D
Medicare coverage varies across the different parts of Medicare, which include Medicare Part A, Medicare Part B, Medicare Part C — also known as Medicare Advantage — and Medicare Part D.
Nicole Toneatti, a Columbus, Ohio-based licensed insurance agent with HealthMarkets Insurance Agency, says that the different Medicare plans come with their own perks and payment requirements — some of which may suit one cancer patient’s needs better than another. Some patients combine plans or add in a supplemental insurance plan (Medigap) to increase the range of their coverage, Toneatti adds.
“They really need to understand the rules of the game before they can really decide what is the best plan for them,” Toneatti says.
Here’s an overview of Medicare’s cancer coverage under different types of plans:
— Medicare Part A (hospital insurance)
— Medicare Part B (medical insurance)
— Medicare Part C (Medicare Advantage)
— Medicare Part D (prescription drug coverage)
[READ: Does Medicare Require Prior Authorization?]
Medicare Part A Coverage for Cancer Treatments
Medicare Part A provides coverage for inpatient care, generally covering services for short-term stays deemed medically necessary. For people receiving cancer treatments, this can include coverage for some cancer treatments you receive during an inpatient stay at the hospital.
Some cancer treatments that fall under Medicare Part A coverage include:
— Inpatient cancer-related surgeries and hospital stays surrounding surgeries
— Skilled nursing facility care following a three-day inpatient hospital stay
— Some home health care
— Inpatient blood transfusions
— Some inpatient clinical research costs
— Surgically implanted breast prostheses following a mastectomy (in an inpatient setting)
Medicare Part B Coverage for Cancer Treatments
Medicare Part B covers outpatient care. For people with cancer, this can include coverage for certain doctor’s visits and treatments for people who are receiving medical care without long-term hospital stays.
Some cancer treatments that fall under Medicare Part B include:
— Outpatient chemotherapy
— Outpatient radiation for cancer
— Outpatient surgery for cancer
— Some medical equipment, such as wheelchairs, walkers and hospital beds
— Home health care
— Some cancer screenings and diagnostic tests
— Doctor’s office visits
— Certain oral anti-cancer drugs
— Second opinions on surgery
[READ: Medicare Mistakes to Avoid.]
Medicare Advantage (Part C) Plans Coverage for Cancer Treatments
Medicare Advantage is a type of health insurance plan provided by private insurance companies that contract with Medicare. It combines benefits of Medicare Part A, Medicare Part B and sometimes Part D into a single plan. As such, people with Medicare Advantage plans receive coverage for all cancer treatments included under Medicare Parts A and B, at minimum.
Medicare Advantage users may also have some additional benefits, like dental and vision services, reduced cost sharing and caps on out-of-pocket costs. But while Medicare Advantage plans have a few extra offerings, they come with drawbacks too.
Dr. Wael Harb, a board-certified medical oncologist at MemorialCare Cancer Institute at Orange Coast and Saddleback Medical Centers in Orange County, California, says that many of Medicare Advantage’s plans “come with trade-offs, such as more constrained provider networks and stricter coverage restrictions, including prior authorizations and step therapy — which can impact access to certain treatments.”
Harb explains that patients waiting for prior authorizations may not receive coverage for the cancer treatments they need at the time they need it. Additionally, step therapy — an insurance-driven process that requires patients to try one treatment or therapy before accessing another, often more expensive option — can delay a patient from getting treatment, he says.
[Read: Where to Go for Cancer Treatment.]
Medicare Part D Coverage for Cancer Treatments
Medicare Part D provides prescription drug coverage. Your plan should have a formulary, which is a list of covered medications. For people receiving cancer treatments, this may include prescribed pain medications or anti-nausea medications. It may also include oral chemotherapy drugs, if prescribed.
It’s important to check that the medications your doctor prescribes you are on the formulary. That’s because some of the most significant issues for Medicare beneficiaries arise with high-cost medications or procedures that are either not fully covered or are covered with high co-pays or deductibles, Harb says.
“The financial toxicity for patients can be severe, especially for those on Medicare Part D facing high out-of-pocket costs for oral medications,” Harb says.
Challenges increase when trying to prescribe newer, higher-cost cancer therapies, like certain immunotherapies, he adds.
And for better or worse, when a patient needs one of these novel therapies, financial challenges can be almost unavoidable.
“Drugs not being on a formulary is an issue not only for Medicare but everyone,” Toneatti says. “It’s a pain point for a lot of people.”
Unique to oncology, however, Toneatti says that drugs may be more often excluded from Medicare plans because they are brand new, or only just received a Food and Drug Administration approval. When running into issues where Medicare won’t cover a necessary prescription drug, she adds that doctors and insurance agents can do their best to raise the issue to that patient’s Medicare carrier or start an appeals process explaining why the patient needs coverage for a certain medication. They can also help the patient find alternative medications or alternative methods of paying for the drug.
Harb says that insufficient coverage can at times force doctors to adjust the patient’s plan, prescribing an alternative that is covered by Medicare. This can only be done with “careful consideration to ensure the patient is still receiving optimal care,” he adds.
[READ: What to Do When Medicare Advantage Plans Deny Coverage]
Does Medicare Cover Chemotherapy?
Generally, Medicare covers chemotherapy. However, exact coverage can vary depending on what plan you have and what type of chemo you are getting. For example, Medicare Part A covers inpatient chemotherapy, which can come with a copay. Medicare Part B covers chemotherapy in a doctor’s office or clinic, for which patients pay 20% of the Medicare pre-approved amount, which they can apply to their Part B deductible. Medicare Parts B and D cover some oral chemotherapy drugs.
For Medicare Advantage plans, patients may pay co-pays or share some of the costs of treatment, with some plans charging a cost share of up to 20% of their chemotherapy cost. People must pay required co-pays and cost shares until they reach that year’s out-of-pocket maximum. After the maximum is reached, Medicare Advantage plans fund 100% of remaining treatments that year.
How Much Does Cancer Treatment Cost With Medicare?
A 2022 report found that insured patients diagnosed with cancer at later stages (III/IV) had a higher three-year total out-of-pocket cost compared to those diagnosed at earlier stages (I/II), and this cost reached as high as $35,243 among patients diagnosed with stage IV lung cancer.
A similar report from 2021 that looked specifically at Medicare beneficiaries with cancer found that in the first year, total costs for Stage I diagnoses varied from $7,640 (prostate cancer) to $94,636 (pancreatic cancer). Total costs increased by stage and reached $58,783 (prostate cancer) to $156,982 ((stomach cancer) for Stage IV diagnoses in the first year. Medicare beneficiaries diagnosed at later stages of cancer have higher costs of care (up to seven times as much) than those diagnosed at earlier stages.
These findings make the case for early detection and preventative screenings for cancer all the more important.
Medicare Coverage for Cancer Prevention
Medicare Part B covers some preventive cancer services, such as screenings and certain care management services. These include:
— Cervical and vaginal cancer screenings. Cervical and vaginal cancer screenings are covered once every 24 months in most cases, or every 12 months for people who are either at high risk for cancer or who are of child-bearing age with an abnormal pap test in the last 36 months.
— Breast cancer screenings. Clinical breast exams are covered once every 24 months for most women. Mammograms are also generally covered once every 12 months for women 40 or older, and women 35 to 39 may receive coverage for one baseline mammogram exam. Diagnostic mammograms are typically covered more frequently, with beneficiaries being responsible for 20% of Medicare-approved costs.
— Some types of colorectal cancer screenings. Depending on your age, surgical history and risk level, Medicare may cover one or more types of colorectal cancer screening tests, such as a barium enema, screening colonoscopy, flexible sigmoidoscopy, fecal occult blood tests and/or a multi-target stool DNA and blood-based biomarker test.
— Lung cancer screenings. Lung cancer screenings are covered for people between ages 50 and 77 who meet certain requirements, including those with a history of heavy smoking. To qualify, patients must have a smoking history of at least 20 “pack-years” — meaning an average of one pack per day — and must currently smoke or have quit within the last 15 years.
— Prostate cancer screenings. Medicare fully covers prostate specific antigen, or PSA, tests once every 12 months for men age 50 and older. Under Part B, Medicare also covers a digital rectal exam, for which patients will pay 20% of the Medicare pre-approved amount — and potentially a copay, depending on where the exam is conducted.
— Some principle care management services. These refer to some types of care management services for a disease, like cancer, that puts you at risk for physical or cognitive decline, hospitalization or death.
Medicare Coverage for Cancer-Related Services
While it might not meet all your coverage needs, Medicare does offer a few extra coverage benefits pertaining to cancer that you might not have known about.
For instance, Medicare may at times cover some dental care if relevant to cancer-related treatments — even though, generally, only Medicare Advantage (and not original Medicare) offers dental care coverage. Medicare may also at times cover innovative models and pilot projects related to cancer care, such as innovations in dementia treatment or a new procedure.
What’s more, if you’re experiencing chronic lower back pain from an unknown cause — which could include cancer — Medicare Part B will cover acupuncture services. Medicare only covers acupuncture for chronic lower back pain, and will cover a minimum of 12 sessions in 90 days, or an additional eight sessions within a 12-month total period if you are showing improvement.
Getting the Most Out of Your Medicare Plan
Medicare costs aside, battling cancer is taxing. It can help to have someone working with you on the financial side to make sure you are getting the most out of your Medicare plan. Sometimes, your doctor can be that person for you. If not your doctor directly, your doctor likely has a financial team that can help with insurance-based communications. Don’t be afraid to ask questions and advocate for yourself if a treatment isn’t covered by your plan. Your State Health Insurance Assistance Program (SHIP) can offer free and unbiased insurance counseling to Medicare-eligible individuals and their caregivers.
Harb says when one of his patient’s cancer treatments isn’t covered by Medicare, his first step is typically to appeal the decision to Medicare, which often requires him to provide clinical documentation to support why he thinks the patient needs the treatment.
“This can be a time-consuming process and may involve multiple rounds of communication with the insurer,” Harb says. “The growing administrative burden associated with these processes, especially under Medicare Advantage, can be distressing for clinicians and patients alike, highlighting the need for policy innovations that balance cost control with access to necessary care.”
When working with patients on these issues, Toneatti says she encourages people to think about if the medication is being offered through any research studies, which might lower the costs, or if the patient could access any patient assistance programs to help with expenses.
Overall, she says not to let a high out-of-pocket estimate discourage you from looking for solutions.
“There’s a lot of other ways to search for your ‘yes’ to get that medication,” Toneatti says.
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Does Medicare Cover Cancer Treatment? originally appeared on usnews.com
