Regardless of who you are, the reality of a cancer diagnosis is inherently difficult. However, due to advances in modern technology and decades of highly funded research, there exist more proven cancer treatment methods than ever before. Luckily, Medicare covers the cost of most treatments to varying degrees depending on the nature of your diagnosis and a few other factors.
Does Medicare Cover Cancer Treatments?
Generally, Medicare covers cancer treatment as long as a doctor who accepts Medicare prescribes it, though keep in mind that not all treatments are covered.
Medicare splits down into four sections–Medicare Part A and Part B (which together form Original Medicare), Medicare Part C (aka Medicare Advantage), and Medicare Part D (the drug plan). Each section of Medicare kicks in to cover different areas of treatment.
Original Medicare includes two parts: Medicare Part A (hospital insurance) and Part B (medical insurance). Original Medicare covers its portion of the Medicare-approved amount–typically 80% of the cost of treatment–leaving you to pay what’s left of the treatment costs through deductibles and coinsurance.
Medicare Part A
Medicare Part A covers any cancer treatment or testing during your time in the hospital. Some cancer treatment costs in this category include:
- Impatient chemotherapy
- Impatient hospital stays following surgery
- Time in a skilled nursing facility
- Home healthcare, like physical or occupational therapy
- Surgically implanted breast prostheses following a mastectomy
- Hospice care
- Blood transfusions
- Clinical research and diagnostic testing that occurs in the hospital
Most people do not need to pay a monthly premium for Medicare Part A; you just need to meet a deductible and occasionally pay for coinsurance. Multiple hospital stays might require a new deductible with each visit.
Medicare Part B
Medicare Part B, in turn, covers any medically necessary outpatient treatment. Most cancer care falls under Medicare Part B coverage, including:
- Visits to your general practitioner, oncologist, and any other specialists
- Radiation therapy at outpatient facilities
- Diagnostic testing, like X-rays or bloodwork
- Outpatient surgery
- Intravenous and some oral forms of chemotherapy
- Durable medical equipment, like walkers, wheelchairs, or oxygen tanks
- Mental health services
- Preventative care screenings
Medicare Part B typically covers 80% of the Medicare-approved outpatient cancer care, leaving you to pay the remaining 20% of the bill. You would also pay a smaller deductible than with Medicare Part A.
Medicare Part C (Medicare Advantage)
Medicare Part C–aka Medicare Advantage–must at the bare minimum offer all the same benefits as Original Medicare (Parts A and B), and can sometimes bundle in Medicare Part D as well as additional benefits. Private companies finance Medicare Advantage plans; while premiums tend to be a bit higher, you’ll see the payoff in the form of more expansive coverage upon starting your treatment.
Medicare Advantage plans usually require you to stick within a network of specific doctors to receive care. You typically still need to pay coinsurance until you reach an annual maximum. You cannot supplement your Medicare Advantage plan using Medigap, as detailed further down this list.
Medicare Part D (Prescription Drug)
Medicare Part D plans specifically cover retail prescription drugs. You must elect to include Part D in your Original Medicare or Medicare Advantage plan and pay an additional premium. Part D could cover up to 95% of certain oral chemotherapy drugs, antinausea medications, pain pills, and other prescriptions related to your cancer treatment, requiring only a small copay. Different plans might offer or omit certain kinds of drugs.
Medigap (Medicare Supplement)
Private insurance companies can also provide optional Medicare Supplement–aka Medigap–plans to fill specific gaps in coverage left by your core Medicare plan. Medigap knocks down or squarely eliminates some out-of-pocket copay, coinsurance, and deductible costs in exchange for an annual premium. You receive more or fewer benefits, conditional to the premium you choose to pay.
Common Cancer Types for Those Over 65
Although cancer affects people of all ages, studies show the elderly are at an exponentially higher risk of diagnosis–about ten times more likely. Medicare beneficiaries with cancer must pay higher out-of-pocket costs than cancer-free beneficiaries, which often vary depending on the type of cancer. The most common forms of cancer found in those over the age of 65 include:
Cervical cancer occurs in the cells of the cervix, the lower part of the uterus connecting to the vagina. Cervical cancer stems from HPV (human papillomavirus), typically spread through sexual contact. More than 20% of cervical cancer cases are found in women over 65, though they rarely occur in women who have sought regular testing over the decades.
Medicare Part B fully covers pap smear tests and pelvic exams to check for cervical cancer or HPV, allocating one set of free tests every two years. If you are at high risk or of child-bearing age, you become eligible for these tests once per year.
Prostate cancer–one of the most common types of cancer–grows in the prostate, a small gland found in men that produces semen. More than half of new prostate cancer cases occur in men over the age of 65 and rarely turn up in anybody under 40 years old.
Preventive screening measures for prostate cancer–specifically rectal exams and PSA tests–should be 100% covered by Original Medicare as long as you qualify and receive service through an approved doctor. Medicare will not ask you to pay a deductible, copay, or coinsurance for preventative tests.
Colorectal cancer–often referred to as colon cancer for short–occurs when cells in the colon or rectum grow out of control. 90% of colon cancer cases appear in individuals age 50 or older and can stem from genetic disposition, as well as lifestyle choices like diet and substance intake.
If you are at high risk of colon cancer, Medicare fully covers preventative screenings such as colonoscopies once every two years. If your doctor finds nothing, the exam is free. If they surgically remove a polyp or any other tissue in the process of the exam, you must pay 15% of your Medicare-approved amount.
Lung cancer is the leading cause of cancer deaths worldwide and most commonly occurs in people over 65. Cigarette smokers are at much higher risk for lung cancer, but it can occasionally show up in people who’ve never even touched a cigarette. The longer you’ve smoked, the higher your risk–though risk does drop substantially over time after quitting.
Medicare Part B will cover 100% of low-dose computer tomography screenings for lung cancer every 12 months for anyone between the ages of 50-77, current or previous long-term smokers, and anyone not currently displaying clear signs of lung cancer.
Breast cancer is the second most common type of cancer found in women, following only skin cancer. Nearly half of new breast cancer cases occur in women over 65, and those who develop early-onset breast cancer in their later years have a notably lower likelihood of survival.
Medicare covers 100% of preventative mammograms (breast examinations) performed by a certified doctor once every 12 months for all women aged 40 or over. Medicare Part B would also cover 80% of the Medicare-approved amount for any other medically necessary examinations within the same year, leaving you to pay the remaining 20% of the Medicare-approved amount on top of the Part B deductible.
Common Cancer Treatment Options
Cancer treatment plans can vary widely depending on the individual and their diagnosis. Most treatment plans develop under a team of specialized doctors and typically include one or more of the following forms of treatment, each of which Medicare covers to varying degrees:
Chemotherapy delivers powerful chemicals orally or intravenously to kill cancer cells or stop them from spreading. Though chemotherapy can effectively treat many types of cancer, it carries a fair risk of distressing, life-altering side effects such as hair loss, extreme fatigue, loss of appetite, and debilitating nausea.
Medicare should cover any chemotherapy approved by your doctor. Medicare Part A would take care of chemotherapy introduced at the hospital, and Part B would cover any procedures performed at home or a doctor’s office. Occasionally, Medicare Part D could kick in to cover specific pill-form chemotherapy treatments.
Radiation therapy kills cancer cells by blasting them with high-energy particles, such as X-rays or protons. Radiation therapy can be employed before or after surgery or in combination with other treatment methods like chemotherapy to shrink a tumor for extraction.
Original Medicare would mostly cover any medically necessary radiation therapy. Part A would cover any hospital radiation procedures, and Part B would cover any outpatient radiation therapy. With Part A, you would only pay the deductible and applicable coinsurance. Part B would leave you with 20% of the Medicare-approved amount after you cover your deductible and copays.
While cancer surgery aims to remove all the cancerous material from your body, it can also be effective in preventing, diagnosing, staging, or debulking a large cancerous tumor. For the best result, doctors elect surgery in conjunction with other treatment methods like chemotherapy and radiation.
Medicare covers most medically necessary surgical procedures. Generating cost estimates in advance can be difficult with surgery because you won’t know what services you need until you meet with your provider. As with everything else, Medicare Part A would address any inpatient procedures, and Part B would cover 80% of outpatient surgeries.
Hormone therapy explicitly treats cancer that feeds off hormones by removing or replacing those hormones in the body. Examples include breast and prostate cancer, which respectively feed off estrogen and testosterone. Original Medicare will not cover hormone therapy, though a Medicare Advantage plan or Medicare Part D supplement might.
A relatively new form of treatment, gene therapy replaces or modifies genetically mutated or cancerous cells in the body. Medicare only covers certain forms of gene therapy, and progress for Medicare in this area often comes against bureaucratic blockades. As this treatment method grows and develops, Medicare will hopefully expand to help cover a broader range of genetic therapy and testing.
Immunotherapy helps you fight cancer by beefing up your immune system and steering its focus toward cancerous cells in your body. Medicare covers immunotherapy similarly to all other covered treatments. Part A would cover the bulk of inpatient procedures after your deductible and coinsurance, Part B would cover 80% of outpatient costs, and Part D would cover certain prescribed immunotherapy medications.
What Medicare Exclusions Are There For Cancer Treatments?
A Medicare-approved doctor must declare any cancer treatment medically necessary to qualify for coverage. For example–a wig purchased to compensate for hair loss related to chemotherapy treatment will not qualify as eligible, as this is not “medically necessary.” Additionally, Medicare might exclude some of these other nebulous, cancer-related costs:
- Room and board in an assisted living facility
- Assistance with daily living–like eating or bathing–that does not require skilled care
- Adult daycare
- Medical food or nutritional supplements
- Long-term nursing home care
Patients can work with their doctors to devise a treatment plan that falls within the bounds of their Medicare coverage. Many parallel routes to recovery often exist if your initial treatment plan does not wholly align with your Medicare coverage. Adjusting treatment to match your eligible coverage could save you thousands of dollars.