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Updated onMay. 18, 2022

Medicare And Cancer Treatment Coverage

In 2009, just over 50 percent of all cancers occurred in individuals 65 years old or older, according to research published in the American Journal of Preventive Medicine. By the year 2030, though, that number is expected to grow to 70 percent. What is the cause of this level of increase?

senior man talking to a doctor

The study’s authors say that there are many factors that can potentially increase an elderly person’s risk of developing cancer. For instance, exposure to chemical agents, radiation, and smoking tobacco can all play a role. There are several health conditions that can raise a person’s cancer risk as well, and they include:

  • Diabetes: Linked to cancers of the breasts, colon, and pancreas
  • Obesity: Linked to cancers in the esophagus, pancreas, thyroid, gallbladder, colon, rectum, breasts, endometrium, and kidneys
  • Hepatitis C: Increases risk of hepatocellular carcinoma, a cancer that begins in the liver
  • HIV (human immunodeficiency virus): Associated with anal cancer, liver cancer, and Hodgkin’s disease
  • HPV (human papillomavirus): Related to cancers in the cervix, vulva, penis, anus, and oropharynx (the middle part of the throat)

Regardless of the factors contributing to the development of cancer, treatment is often a major expense. According to the AARP, the average cost for cancer treatment is somewhere around $150,000. With a price tag this big, some patients will modify their treatment plans in an effort to reduce their expenses. This is a major concern with a health condition like cancer because approximately 609,640 people die each year from this category of diseases, according to the National Cancer Institute. This makes it the second-leading cause of death in the U.S. and globally. So, how can Medicare help reduce the financial burden in the event that you receive a cancer diagnosis?

MEDICARE PLAN

If you have cancer and are hospitalized, Medicare Part A (Hospital Insurance) will cover a portion of your “medically-necessary cancer-related services and treatments,” according to Medicare Coverage of Cancer Treatment Services, a guide created by the Centers for Medicare & Medicaid Service (CMS). These services and treatments include:

  • In-patient hospital stays
  • Cancer treatments received while inpatient
  • Blood
  • Some clinical research study costs
  • Hospice care

Medicare Part A also provides coverage related to breast prostheses that are surgically implanted after a mastectomy (as long as you’re still in-patient), home health care services related to rehabilitation, and skilled nursing facility care.

Medicare Part A also provides coverage related to breast prostheses that are surgically implanted after a mastectomy (as long as you’re still in-patient), home health care services related to rehabilitation, and skilled nursing facility care.

Additional expenses related to many outpatient services are also covered under Medicare Part B (Medical Insurance). For instance, Medicare covers certain cancer prevention and screening services. The American Cancer Society (ACS) says that this includes coverage related to the following:

  • The “Welcome to Medicare” visit you have with your doctor within the first year of being enrolled in Medicare Part B
  • Your wellness visit every 12 months
  • Annual lung cancer screening
  • Testing for colorectal cancer, if you’re at average risk for the disease.

For women specifically, cancer prevention and screening services covered by Medicare include one mammogram every 12 months and a Pap test and pelvic exam every 24 months if you’re at risk of cervical cancer. For men over 50, a prostate cancer screening is covered every 12 months. Medicare Part B also provides benefits related to tests commonly used to diagnose cancer, such as x-rays and CT scans. If cancer is found, Medicare Part B provides coverage for a variety of different outpatient treatment options. This includes:

  • Oral or vein-administered chemotherapy
  • Radiation
  • Surgery (sometimes Medicare will cover a second or third opinion if the surgery is non-emergency)
  • Some costs associated with clinical research studies

On March 16, 2018, the CMS issued a release indicating that Medicare also covers diagnostic laboratory tests using Next Generation Sequencing in cases where cancer is advanced. These tests are designed to help healthcare providers find the most effective treatment options based on the individual patient’s genetic mutations. Medicare Part B is the part of the plan that also helps cover costs for equipment that may be needed post-treatment. This includes durable medical equipment like walkers and wheelchairs, in addition to enteral nutrition equipment (a feeding pump) if your doctor prescribes its use for your treatment at home. Breast prosthesis that are surgically implanted in an outpatient setting are typically covered under Part B too, as are mental health services and nutritional counseling (the latter of which is covered only if you also have diabetes or kidney disease).

Golfing Couple

If you have Medicare Advantage (Part C), this means that you’ve purchased your Medicare plan from a private insurance company as opposed to getting it directly from the federal government. These types of plans are required to give you the same basic coverages as Original Medicare, but the CMS warns that they can have “different rules and costs.” Therefore, it’s important to go through your individual plan so you understand what it says regarding cancer coverage specifically. And if any portion of that policy is unclear, follow up with your policy’s administrator so you know what is covered and what isn’t.

If any portion of that policy is unclear, follow up with your policy’s administrator so you know what is covered and what isn’t.

senior couple on the beach

If you receive a cancer diagnosis and want to change your Medicare plan, the CMS says that this request can only take place during very specific times. For instance, if you want to change your policy from Original Medicare to Medicare Advantage, you can only do so during open enrollment, which is between October 15th and December 7th of each year, with coverage initiating January 1st of the following year. However, if your goal is to disenroll in Medicare Advantage and go back to Original Medicare, the time frame for this is January 1st to February 14th.

Medicare Part D covers prescription medications and can either be purchased on its own to add more coverages to Original Medicare, or sometimes it is a benefit that is lumped in with an all-in-one type of Medicare Advantage Plan. If you have it as part of Original Medicare, the ACS says that it is still more likely that your medications will be covered under Part B instead. This is because the main cancer-related drugs—chemotherapy and anti-nausea medications—are administered via IV, which classifies them as an outpatient service. On the other hand, if you take your cancer drugs orally, these are typically covered under Part D, the actual Medicare prescription plan. Additionally, if you’re new to the Medicare prescription drug plan and it does not cover the medication you’re currently taking as a result of having cancer, the CMS says that “the plan must let you get a 30-day temporary supply of the prescription (a 91-day supply if you’re the resident of a long-term care facility).” This gives you time to work with your healthcare provider to find a drug that is just as effective and also covered under your new plan.

Some Medicare participants choose to purchase a Medigap policy. Medicare.gov explains that these supplemental policies are used to help cover costs not traditionally covered by Medicare plans, such as copays, coinsurance, and deductibles. But there are also some costs that these policies don’t cover that may relate to cancer-related care. A major one is prescription drugs (for all policies sold after January 1, 2006). Medigap also does not have benefits related to vision or dental, hearing aids, eyeglasses, private-duty nursing, or long-term care.

elderly couple planning life insurance

While Medicare may cover a large portion of the costs associated with of cancer prevention, diagnosis, and treatment, you may still have to pay for certain things.

For instance, if you have Medicare, you are still responsible for all copayments, coinsurance, and deductibles required under your specific plan. Plus, there are some services that Medicare only covers a portion of. In these cases, the remaining balance is your responsibility.

Sometimes, Medicare won’t cover the costs at all, according to the CMS. These costs include:

  • Daily living assistance services
  • Adult day care
  • Assisted living room and board
  • Long-term nursing home care

Additionally, while Medicare does cover a feeding pump, it will not pay for medical food or nutritional supplements. What can you do if Medicare doesn’t pay for something you think it should?

older women receiving help at home

You have the right to file an appeal in the event that Medicare does not reimburse a healthcare provider or service for something that you feel should be covered. That goes for whether you’ve already received the service or item, or if you believe that you should be eligible to receive it.

There are five levels to the appeals process that give you the opportunity to take your appeal all of the way to a judicial review by a federal district judge if you disagree with the decision made at any stage.

The exact process you will follow to go through this process depends on which type of Medicare plan you have. Also, if you need help with filing your appeal, you can either appoint a representative to help you (a family member, friend, or healthcare provider, for instance) or contact your State Health Insurance Assistance Program.

Although Medicare has traditionally provided a number of medical treatment benefits related to cancer, it has consistently fallen short is with regard to the hair loss many cancer treatment patients experience. More specifically, it has never helped with the cost of purchasing a wig. However, some U.S. legislators are hoping to change that. On June 15, 2017, Rep. James P. McGovern introduced a bill (H.R. 2925) that would amend title XVIII of the Social Security Act to include wigs—what the bill refers to as “medically necessary cranial prostheses”—as durable medical equipment under the Medicare program. If this bill passes, cancer patients with Medicare could get some or all of their wig-related expenses covered or reimbursed.

If you have Medicare and are diagnosed with cancer, the ACS recommends that—prior to scheduling any type of doctor’s appointment or test—you first ensure that the healthcare providers you’ve chosen accept your Medicare insurance plan. If they don’t, you may be required to pay some or all of their costs up front. Yes, Medicare may reimburse you for some of these expenses, but only the amounts dictated by your individual plan. So, if the provider charges more than Medicare is obligated by your policy to pay, you are responsible for the balance. The ACS also says that some doctors have completely opted out of Medicare, which means that if you decide to use them, Medicare won’t pay any of the costs incurred. In this instance, you would have to pay for everything. Medicare offers many benefits related to cancer, but there are also some it doesn’t. That’s why it’s critical to familiarize yourself with your specific plan. And if you have questions, ask. In the meantime, Medicare.gov has provided the forms and resources necessary to help you understand what your Medicare policy can (and cannot) do for you.

young woman talking to older man with dementia