Does Medicare Cover Chemotherapy?Chemotherapy: What Is It, Who Needs It, and How Medicare Can Cover Cancer Treatments
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More than 1.6 million people are diagnosed with cancer, and almost 600,000 cancer deaths are reported in the U.S each year, making it the country’s second leading cause of death.
According to HealthDay News, the cost of cancer care continues to rise with $21.09 billion spent on it in 2019. This comprises patient out-of-pocket costs of $16.22 billion and patient time costs of $4.87 billion.
In this article, we will discuss what chemotherapy is, how much it costs, and whether Medicare can help you cover it.
What Is Chemotherapy?
Chemotherapy is the name given to a range of medicines that are used to treat cancer and other diseases.
They work by targeting and killing fast-multiplying cells within the body. There are different types of chemotherapy treatments that have been developed over the years.
Chemotherapy can be administered on its own or paired with other cancer-fighting treatments like immunotherapy, radiotherapy, and hormone therapy.
Side Effects of Chemotherapy
Chemotherapy is a good way to treat many types of cancer.
However, there is also a chance that it will cause side effects. Some of the side effects of chemotherapy can be mild and treatable, but others can be very dangerous. Some of these include:
Anemia (i.e. lack of red blood cells)
Bruising and bleeding
Loss of appetite
When Is Chemotherapy Used?
It is mostly used to kill cancer cells in cancer patients. There are a lot of situations where chemotherapy can be used to treat people who have cancer, including:
To cure cancer without other treatments. Chemotherapy can be used as the main treatment for cancer.
After other treatments, to kill hidden cancer cells. It can be used after other treatments like surgery to kill any remaining cancer cells. This is called "adjuvant therapy."
To prepare you for other treatments. Other treatments are sometimes done after chemotherapy, such as radiation and surgery. This is called “neoadjuvant therapy.”
To ease signs and symptoms. Chemotherapy may be able to help relieve some of the symptoms and signs of cancer because it kills some of the cancer cells. This is called “palliative chemotherapy.”
What Non-Cancer Conditions is Chemotherapy Used For?
Some chemotherapy drugs have proved useful in treating other conditions, such as:
Bone marrow diseases.
Immune system disorders, such as lupus and rheumatoid arthritis.
Does Medicare Cover Cancer Treatment?
Yes, Medicare will cover cancer treatment for Medicare beneficiaries, including chemotherapy that is prescribed by a Medicare-accepted doctor.
However, you’ll need to be enrolled in both Part A and Part B to get full coverage for all cancer-related treatment costs.
Medicare will pay for you to see two surgical oncologists before surgery. If the two doctors don't agree, Medicare will pay for you to go to a third doctor.
As long as you have Medicare, you can get cancer treatment at any age. If you want the prescription drugs that are part of your cancer treatment to be covered, you will have to get Medicare Part D coverage.
Part D is merely descriptive of the different costs. You still need to buy coverage to get Part D expenses covered.
Medicare Part A (Inpatient care) covers the care and treatment of patients in hospitals and other medical facilities. For example, hospice care and skilled nursing facility care.
What Is Inpatient Care?
Inpatient care is care provided in a hospital or other type of inpatient facility, where you are admitted, and spend at least one night — sometimes more — depending on your condition.
Cancer care and services Part A covers include:
Cancer treatment, such as chemotherapy and blood transfusions.
Inpatient diagnostic tests to find out what's wrong with your body (e.g. to identify cancer).
Inpatient surgical procedures to remove cancerous masses and growths.
Surgically implanting breast prostheses after a mastectomy.
What Is a Mastectomy?
Mastectomy is the partial or complete surgical removal of one or both breasts to treat breast cancer.
Medicare Part B covers medically necessary outpatient care and covers most types of cancer treatment, including chemotherapy.
What Is Outpatient Care?
Outpatient care is any procedure that does not require hospital admission or that is performed outside the premises of a hospital.
Cancer care and services covered by part B include:
Visits to your general practitioner, oncologist, and other specialists.
Diagnostic testing (such as X-rays and blood work).
Ambulatory surgery (when you can go home the same day).
Intravenous (administered through the veins) and some oral chemotherapy treatments.
Durable medical equipment (such as walkers, wheelchairs, and feeding pumps).
Medicare Advantage Plans
Medicare Part C, or Medicare Advantage, are private plans offered by private insurance companies that have all the benefits of Original Medicare (Parts A and B).
These plans also usually have additional Medicare coverage for dental, hearing, and vision care. Most also cover Part D expenses.
What Are Part D Expenses?
They are costs for prescription drug coverage that relate to chemotherapy (i.e. some are in pill form that you take at home).
If you are on a Medicare Advantage plan, you can expect the same level of cover as you would receive on Original Medicare. This is because all Medicare Advantage plans must offer equivalent cover to their members.
What Is “Equivalent Cover?”
Equivalent cover refers to an insurance policy that is equal to your current policy in terms of cost, scope, exclusions, deductibles, and limitations.
For example, if Original Medicare covers cancer treatment, surgery, and mental health services, Medicare Advantage needs to cover at least that.
If you are unsure about equivalent coverage, send your questions to Help@PolicyScout.com or call us on 1-888-912-2132 to get personalized assistance from one of our skilled Medicare consultants.
Stand-alone Prescription Drug Plans
It's possible that a stand-alone prescription drug plan will pay for some of the medicine your doctor gives you as part of your cancer treatment.
Prescription drug coverage usually include:
Oral chemotherapy drugs
What Are the Out-Of-Pocket Costs of Cancer Treatment Services?
Before you begin your chemotherapy treatment, be aware that there might be out-of-pocket expenses that Medicare won’t cover.
Keep in mind that you’ll be liable for a deductible and coinsurance on your treatment costs.
In 2022, Part A deductible was $1,556 and the coinsurance amount is $0 per the first 60 days and increased after day 60.
The Part B deductible is $223 and the coinsurance amount is 20% of the total cost of treatment.
What Is a Deductible?
A deductible is an amount that people have to cover before their Medicare plan or insurance starts to pay for medical expenses.
Another tip is to check whether your doctor or healthcare facility is covered by Medicare. If you receive treatment at a facility that doesn't accept Medicare patients you will be liable for more than 20% of the costs.
Check with your doctor or hospital to see if they "accept Medicare assignment."
What Does It Mean When a Doctor Accepts Assignment?
Accepting assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.
However, doctors who haven't signed up for Medicare may charge you more than Medicare will pay for your treatment, leaving you to pay the rest, as well as your copayment.
What Is a Copayment?
Copayments are set amounts or rates that Medicare beneficiaries pay for medical services, tests, and items.
Out-of-pocket costs for cancer treatment such as chemotherapy depends on:
The type of cancer you have.
How aggressive the cancer is.
The type of treatment your doctors prescribe.
According to CostHelper.com, the cost of chemotherapy varies greatly. Generally, if you have Medicare, you can expect to pay 10% to 15% of chemo costs out-of-pocket.
However, if you don't have Medicare, you could pay between $10,000 to $200,000.
Medicare Part B usually pays for 80% of outpatient cancer care, like radiation therapy and chemotherapy, after a $203 deductible. The insured person is responsible for the rest of the costs.
If your treatment includes hospital stays, inpatient surgery, or other types of inpatient treatment, it could start to cost a lot more, even if you have Medicare or other insurance.
To learn about Medicare costs, read our article on Part A and Part B expenses.
What Else Does Medicare Cover?
If you have cancer and are looking for Medicare coverage, send your questions to Help@PolicyScout.com or call us on 1-888-912-2132 to get personalized assistance from one of our skilled Medicare consultants.
If you are looking for more information about Original Medicare, Medicare Advantage Plans, or anything Medicare-related, head to PolicyScout’s Medicare hub to compare your options and find the best plan in your area.