Medicare Coverage for Cancer Treatments: Understanding Your Options

Does Medicare Cover Cancer Treatments? 

Yes, Medicare generally covers cancer treatment as long as a doctor who accepts Medicare deems it is necessary. However, keep in mind that not all treatments are covered. Regardless of who you are, the reality of a cancer diagnosis is inherently difficult. However, advances in modern technology and decades of research means there are more proven cancer treatment methods than ever before. Medicare covers the cost of most treatments to varying degrees depending on the nature of your diagnosis and a few other factors.

How Does Medicare Cover Cancer Treatments?

Original Medicare is comprised of two parts: Part A (hospital insurance) and Part B (medical insurance). These parts help pay for specific treatments based on where you receive your care, but beneficiaries must meet specific criteria for coverage.

Medicare Part A 

Medicare Part A covers cancer treatment or testing you receive during your time in the hospital. Some cancer treatment costs in this category include:

• Inpatient hospital stays
• Inpatient chemotherapy, surgeries, and other cancer treatments
• Time in a skilled nursing facility after a hospital stay
• Home healthcare, like physical or occupational therapy
• Blood transfusions
• Clinical research and diagnostic testing that occurs in the hospital
• Hospice care

However, as Part A only covers inpatient services, beneficiaries should be aware of when their status changes from inpatient to outpatient. This can occur even if you are still physically in the hospital, such as if you are placed in observation to determine if you should be moved to an outpatient setting.

Part A Eligibility

To be eligible for cancer treatment coverage with Part A, your physician must verify that you have cancer. All covered services must be prescribed or ordered by your physician. In addition, Part A will only cover inpatient care.

Part A Costs

After you have met the Part A deductible ($1,600 per benefit period in 2023), your inpatient care will be covered by Medicare at the following rates:

Days of Stay per Benefit Period	Hospital Stay Daily Cost	Skilled Nursing Facility Daily Cost
1-60	$0; Medicare pays 100% of costs	—
61-90	$400 per day	—
91 and more	$800 per day; up to a maximum of 60 days over lifetime	—
1-20	—	$0; Medicare pays 100% of costs
21-100	—	$200 per day
101 and more	—	100% of costs; Medicare no longer covers beyond 100 days

Inpatient and outpatient status is important to keep in mind, as all outpatient care is handled by Medicare Part B, and so has its own deductible, copays, and coinsurance structures.

Medicare Part B 

Medicare Part B 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
• Surgically implanted breast prostheses following a mastectomy if performed in outpatient setting

Part B Eligibility

To be eligible for cancer treatment coverage with Part B, your physician must verify that you have cancer. All services and appointments must be recommended, prescribed, or ordered by your physician. However, Part B may not cover everything your doctor recommends, so be sure you understand what will be your responsibility to pay if not covered by Medicare.

Part B Costs

Once you meet the Part B deductible ($226 for 2023), Medicare Part B typically covers 80% of the Medicare-approved amount for outpatient cancer care. You would pay the remaining 20% of the cost out of pocket.

How Does Medicare Advantage Cover Cancer Treatments?

Medicare Advantage — also known as Medicare Part C — replaces Original Medicare and so must offer the same benefits as Original Medicare at minimum. These plans are offered by private insurance companies, and often include additional benefits that can be beneficial for cancer patients, such as wellness programs, care coordination services, and transportation to medical appointments.

Many Medicare Advantage plans also bundle Part D prescription drug coverage, which can help pay for cancer medications such as oral chemotherapy, targeted therapies, immunotherapy, and hormone therapy.

Medicare Advantage Eligibility

Unlike Original Medicare, Medicare Advantage plans have health networks. This means that cancer patients may need to receive treatment from in-network doctors, hospitals, and facilities. It is important to verify that a preferred cancer treatment center or specialist is in network before enrolling in a Medicare Advantage plan.

When comparing Medicare Advantage plans, ensure that your preferred doctors and facilities are in the plan’s network, or work with a trusted agent to find a new suitable plan.

Medicare Advantage Costs

The cost sharing structure of Medicare Advantage plans can differ from Original Medicare, offering different deductibles, coinsurance rates, and copays for covered services. But unlike Original Medicare, these plans feature an annual out-of-pocket maximum, which limits how much a beneficiary would pay for covered services each year.

How Other Medicare Plans Cover Cancer Treatments

Medicare Part D (Prescription Drug)

Medicare Part D plans specifically covers prescription drugs, and are offered as part of a Medicare Advantage plan or as a stand-alone plan to supplement Original Medicare. Part D plans can help lower the cost of prescription medication for cancer patients, covering:

• Oral chemotherapy
• Targeted therapies
• Immunotherapy
• Hormone therapy
• Anti-nausea medications
• Pain medications

Part D Eligibility

Some plans have rules for coverage, including:

• Prior authorization: Some plans require that your physician get approval from your insurer prior to filling your prescription.
• Quantity: Many plans restrict how much medicine can be dispensed at a time, such as only filling prescriptions once per month or per quarter, depending on how often it must be taken.
• Generic first: Some plans require beneficiaries to try the generic version of a name-brand drug before you can be prescribed the more expensive version.

If you have specific medications you must take, ensure that your Part D plan covers it at an affordable price point, or work with a trusted Medicare agent to find a plan that does.

Part D Costs

All Part D plans have their own formulary, or list of specific drugs that they cover. These are categorized into different pricing tiers, which can differ from one plan to another. For example, one insurer may categorize a specific pain management drug in a lower price tier while another places that same drug in a higher price tier. Note that most plans require step therapy, where cheaper medications are tried first prior to newer or more expensive medications.

Medicare Supplement Insurance (Medigap)

Medicare Supplement insurance — also called Medigap — works with Original Medicare to help cover the beneficiary’s costs. For example, some Medigap plans cover Medicare’s Part A and Part B deductibles so that you do not have to for those costs out of pocket when you seek care. This can make receiving cancer treatments more affordable in the long run, especially for those who must regularly receive inpatient care or see specialists throughout the year.

Keep in mind that Medigap is only available to those with Original Medicare, and plan options vary depending on location and when you enroll.

How Medicare Covers Common Cancer Treatment Options 

Treatment	Part A Coverage	Part B Coverage
Chemotherapy	Inpatient hospital copays when delivered in inpatient setting	Medicare covers 80% of approved amount when delivered in outpatient setting
Genetic therapy	Inpatient hospital copays	Not applicable
Hormone therapy	No coverage; covered by some Part C or Part D plans	No coverage; covered by some Part C or Part D plans
Immunotherapy	Inpatient hospital copays when delivered in inpatient setting	Medicare covers 80% of approved amount when delivered in outpatient setting
Radiation therapy	Inpatient hospital copays when delivered in inpatient setting	Medicare covers 80% of approved amount when delivered in outpatient setting
Stem cell transplant	Inpatient hospital copays	Not applicable
Surgery	Inpatient hospital copays when delivered in inpatient setting	Medicare covers 80% of approved amount when delivered in outpatient setting
Targeted therapy	Inpatient hospital copays when delivered in inpatient setting	Medicare covers 80% of approved amount when delivered in outpatient setting

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.

How Each Treatment Method Works

• Chemotherapy: 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 risk of side effects such as hair loss, extreme fatigue, loss of appetite, and nausea. Some Medicare Part D plans cover pill-form chemotherapy treatments.
• Genetic therapy: A relatively new form of treatment, gene therapy replaces or modifies genetically mutated or cancerous cells in the body. Medicare specifically covers CAR T-cell therapy for some forms of leukemia and lymphoma.
• Hormone therapy: Hormone therapy explicitly treats cancer that feeds off hormones by removing or replacing those hormones in the body, such as estrogen in breast cancer and testosterone in prostate cancer. As hormone therapy is typically administered through medication that patients take at home, Medicare Parts A and B do not cover it. Those seeking hormone therapy can consider enrolling in Medicare Advantage or Part D plans that do provide coverage.
• Immunotherapy: This type of treatment engages your immune system and steers its focus toward cancerous cells in your body. This allows your own immune system to attack the cancer cells. Part D covers certain prescribed immunotherapy medications that patients must take at home.
• Radiation therapy: 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.
• Stem cell transplant: Stem cell transplants replace damaged or destroyed bone marrow with healthy stem cells to help produce new blood cells. These stem cells can come from the patient themselves or from a donor. By replacing the damaged bone marrow with healthy stem cells, the body can recover more quickly and continue fighting the cancer.
• Surgery: 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. Surgery is typically done in conjunction with other treatment methods like chemotherapy and radiation.
• Targeted therapy: Targeted therapy is a type of cancer treatment that uses drugs to specifically target and attack cancer cells while leaving healthy cells unharmed. These drugs are designed to block the signals that allow cancer cells to grow and divide uncontrollably, or to trigger the cancer cells to die.

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 be eligible, as this is not “medically necessary.” Additionally, Medicare might exclude some of these other more tangential 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. Cancer patients can also consider Medicare Advantage plans, which tend to cover more cancer-related costs, such as nutritional supplements.

Appealing Medicare Claim Denials

If your cancer treatment was not covered and you believe it should have been, you may appeal the decision. Review the denial notice carefully to understand why the claim was denied. Once you have that information, you can begin the appeals process by filing a request for reconsideration with Medicare.

If the reconsideration is denied, you can continue to appeal the decision through several levels of review, including a hearing with an administrative law judge and even a review by the Medicare Appeals Council.

It is important to keep in mind that the appeals process can be complex, so it may be helpful to seek assistance from a healthcare provider, social worker, or Medicare advocacy organization.

Financial Assistance and Resources for Cancer Patients

Beyond the major Medicare plans, there are other options that may help reduce the overall cost of cancer treatments. These are just a few of the many resources available to help people access healthcare coverage and support:

• Medicare Savings Programs: Medicare Savings Programs are state-run programs that help people with limited incomes pay for their Medicare premiums, deductibles, and other out-of-pocket costs. These programs can provide valuable financial assistance to help ensure that Medicare beneficiaries can access the healthcare they need, including cancer treatments.
• Medicaid and dual eligibility: Medicaid is a joint federal-state program that covers medical expenses for people who meet certain income and eligibility requirements. Dual eligibility refers to people who are eligible for both Medicaid and Medicare, which can help provide comprehensive coverage for medical expenses through Medicare Dual-eligible Special Needs Plans.
• State Health Insurance Assistance Programs (SHIPs): These are local organizations that provide counseling and assistance to help people understand their healthcare coverage options, including Medicare and Medicaid. SHIPs can help answer questions, provide guidance on enrollment, and offer other support services to help people navigate the healthcare system.
• Nonprofit organizations and patient advocacy groups: These groups provide support and education for people with specific medical conditions, including cancer. These organizations can help people manage their health and connect with others who are facing similar challenges.

What This Means For You

For coverage, a physician who accepts Medicare must provide a formal diagnosis and prescribe treatments that could help combat the cancer, extend your lifespan, and improve your quality of life. Medicare generally covers common cancer treatments, including surgeries and chemotherapy, but may be more limited in newer treatments, such as the newest advancements in genetic therapy.

Although cancer affects people of all ages, studies show that those over 65 years old have an exponentially higher risk of diagnosis — about ten times more likely than a younger individual. The most common forms of cancer found in those over the age of 65 include prostate cancer, bladder cancer, colorectal cancer, lung cancer, and breast cancer. As such, it is critical to understand how Medicare covers the cancer treatments that beneficiaries need.

Frequently Asked Questions

Additional Resources

• Medicare.gov’s Coverage of Cancer Treatment Services PDF: https://www.medicare.gov/Pubs/pdf/11931-Cancer-Treatment-Services.pdf