If you or a loved one has been touched by cancer, you know the profound impact it can have. As one of the leading causes of death in the United States, cancer claims the lives of over half a million Americans annually.
For individuals aged 65 and older who are enrolled in Medicare, navigating cancer care can present unique challenges. Common questions include, “What does Medicare cover for cancer treatment?” and “Does Medicare include chemotherapy and surgeries?”
Here’s a detailed look at how Medicare supports cancer care and what you need to know to manage your treatment effectively.
Original Medicare cancer coverage
Medicare covers cancer treatment as long as you use an in-network provider. Medicare Part A covers radiation therapy for inpatients during hospital stays as well as other Medicare-covered services. Medicare Part B covers chemotherapy and radiation therapy in outpatient settings or at other facilities that are not part of a hospital. For cancer diagnosis and treatment, Medicare Advantage (Part C) offers comparable coverages.
Meanwhile, Medicare Part D helps cover the cost of certain — but not all— prescription medications associated with cancer treatments.
Note: Before starting cancer treatment, it’s a good idea to get a second opinion from another cancer specialist, which Medicare covers. If the first and second opinions differ greatly, Medicare may also cover a third opinion.
Medicare Part A: This plan is part of Original Medicare and covers hospital insurance. It typically includes cancer treatments administered during inpatient hospital stays.
The coverage includes:
- Hospital care
- Home health services (e.g., visiting nurses, rehabilitation therapists, home health aides)
- Skilled nursing facility care following a hospital stay
- Some costs associated with clinical research studies conducted during hospital stays
- Surgically implanted breast prostheses post-mastectomy (inpatient setting)
- Hospice care
Medicare Part B: Also a part of Original Medicare, Medicare Part B covers a wide range of medically necessary outpatient services and treatments related to cancer. It’s important to note that patients in the hospital under observation status are still considered outpatients.
Coverage includes:
- Doctor visits
- Diagnostic tests such as X-rays
- Chemotherapy (administered orally or intravenously)
- Radiation therapy in outpatient settings
- Certain outpatient surgeries, including breast prosthesis implants
- Durable medical equipment (e.g., wheelchairs, walkers)
- Second opinions before surgery, and in some cases, third opinions
- Enteral nutrition equipment for home use
- Outpatient mental health services
- Certain preventive services and screenings
- Nutrition counseling for patients with diabetes or kidney disease
- Some costs associated with clinical research studies conducted on an outpatient basis
Medicare Part D: Medicare Prescription Drug Plans (Part D) and Medicare Advantage Plans with Part D typically cover most prescription medications, including some chemotherapy drugs.
If a cancer drug is not covered under Part B, it might be covered under Part D. It’s important to distinguish between them as this affects how you receive and pay for your treatments.
Make sure you verify with your Medicare plan provider that your medications are included in the formulary (the list of covered drugs) and understand the tier classification of the drug, as this impacts your out-of-pocket costs.
If this sounds confusing, a Guided Solutions medicare expert can explain it all, but here’s a brief overview.
- Chemotherapy Coverage
- Medicare Part B covers the majority of chemotherapy drugs, which are medications used to treat cancer. These are administered through an injection, intravenous (IV) infusion, or orally. A key point to remember is that if a chemotherapy drug is available in both injectable and oral forms, Medicare Part B typically covers it.
- However, if a cancer drug is exclusively in oral form — like chemotherapy drugs taken orally, medications to counteract nausea, and pain relievers used during cancer treatment — it will usually fall under Medicare Part D, which is geared toward prescription drugs.
- Anti-Nausea Medication
- Chemotherapy frequently causes nausea and vomiting, making anti-nausea medications essential for many patients. Medicare generally covers these anti-nausea drugs like chemotherapy medications.
- For medications that can be taken either orally or intravenously, Medicare Part B will cover them — but they must be administered within 48 hours of chemotherapy. If the medication is only available in oral form or given more than 48 hours after chemo treatment, coverage falls under Medicare Part D.
Genetic and molecular testing for cancer
Understanding the genetic and molecular profile of cancer can help determine the best treatment options. Medicare covers specific tests, such as tumor biomarker testing and Lynch syndrome testing, to help tailor individualized cancer treatment plans.
Tumor Biomarker Testing: Tumor biomarker testing identifies certain genetic abnormalities in cancer cells, helping to determine the cancer’s responsiveness to specific treatments or the likelihood of recurrence.
Medicare covers biomarker testing for patients who:
- Have recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer.
- Have not been previously tested using the same Next Generation Sequencing (NGS) test for the same primary cancer diagnosis, or need repeat testing due to a new primary cancer diagnosis as determined by the treating physician.
- Are seeking further cancer treatment (e.g., chemotherapy).
The diagnostic laboratory test using NGS must have:
- FDA approval or clearance as a companion in vitro diagnostic.
- An FDA-approved or -cleared indication for use in the patient’s specific cancer.
- Results are provided to the treating physician using a report template to guide treatment options.
For biomarker tests without an FDA-approved companion therapy, coverage is at the discretion of regional Medicare Administrative Contractors (MACs), provided the above criteria are met.
Lynch Syndrome Testing: Lynch syndrome testing in cancer patients begins with tumor testing, and Medicare covers two types:
- Microsatellite Instability (MSI): MSI testing detects changes in the length of microsatellite sequences in tumor DNA compared to normal tissue DNA. These changes indicate a deficiency in the DNA mismatch repair system, which is a hallmark of Lynch syndrome.
- Immunohistochemistry (IHC): IHC testing involves staining tumor tissue samples to check for the presence or absence of specific proteins involved in the DNA mismatch repair system. A lack of these proteins suggests a possible Lynch syndrome.
If these tests indicate Lynch syndrome, patients may be referred for genetic testing for inherited mutations. In families with a known Lynch syndrome mutation (MLH1, MSH2, MSH6, PMS2, or EPCAM), Medicare covers genetic testing only for individuals who:
- Exhibit signs and symptoms of Lynch-associated cancer.
- Have a blood relative with a known Lynch syndrome mutation.
Cancer treatment costs and coverage factors
With cancer treatments, out-of-pocket expenses like deductibles, coinsurance, and copayments usually apply. You have the right to be informed about your out-of-pocket costs. Your doctor’s office and the medical facility should assist you in understanding and planning for these expenses.
The costs you’ll face depend on the following factors:
- Whether your healthcare provider accepts Medicare assignment
- The type of medical facility
- Any additional insurance coverage you might have
- The location where services are provided
Services you may need that are not covered by Medicare
Medicare does not cover certain aspects of cancer care, such as:
- Assistance with daily activities (e.g., bathing)
- Nutritional supplements
- Room and board in assisted living facilities
- Adult day services
- Long-term nursing home care
Selecting a cancer treatment center
Choosing the right cancer treatment center is crucial for receiving optimal care. While you may not have control over where you receive emergency treatment, you can select a preferred center for ongoing care.
Consult your doctor for recommendations and seek advice from others who have firsthand experience with cancer treatment. The National Cancer Institute (NCI) identifies top cancer treatment centers, known as NCI-Designated Cancer Centers, across the nation.
Get help with Medicare’s coverage for cancer treatment
This is definitely a tough time for you. Managing the financial and emotional challenges of cancer care is not easy, and figuring out the ins and outs of Medicare’s coverage for cancer treatment can be confusing.
The insurance experts and Medicare counselors at Guided Solutions can help you understand what services are covered and how to access them. We have the knowledge and experience to provide personalized insights, clear recommendations, and assurance when you’re considering cancer screening and possible treatments. Reach out to us here.