In our monthly New to Medicare webinars (find out about our Medicare webinars), we often get questions about Medicare’s coverage of cancer treatment. Many people have battled or know someone who has battled cancer. It’s only natural when talking about health insurance coverage to wonder how your new coverage will cover cancer.
The great news is that Medicare has extensive coverage for various cancer treatments, including chemotherapy, radiation, oncologist visits, surgeries, and much more. You’ll be able to see any doctor that accepts Medicare, too. You can also improve your benefits by enrolling in a Medigap plan and a Part D drug plan.
Let’s look at how the various parts of Medicare cover cancer treatment.
Your Hospital Coverage
Medicare Part A covers inpatient hospital stays, skilled nursing, home health care, blood transfusions and hospice care. Your deductible for Part A is $1316, which can be covered by a Medigap plan.
Sometimes after a surgery, you may need care in a skilled nursing facility. Medicare covers your first 20 days at no cost to you. Afterwards, you will pay $164.50 per day, for up to 80 additional days of coverage.
Your Outpatient Coverage
Medicare Part B covers outpatient benefits. We often think of this as doctor’s visits, but Part B also covers surgeries, ambulance, diagnostic imaging, chemotherapy, radiation, durable medical equipment and much more.
Cancer patients receiving treatments in a clinical setting will find that their chemotherapy and other injectable drugs fall under Part B. Medicare covers 80% after a small annual deductible ($183 in 2017).
You are responsible for the other 20%, but again, this can also be covered by a Medigap plan. We’ll explain more about these plans below.
Your Retail Drug Coverage
Medicare Part D is optional coverage that you can purchase to pay for retails prescriptions. Think of these as any oral medications or drugs that you yourself pick up at the local pharmacy.
Each Part D insurance company sets its own rates, pharmacy network, formulary and copays for medications. Generic medications will be more affordable than brand name medications in most cases.
There are many common generic cancer drugs that are covered by Part D plans such as tamoxifen and imatinib. Before enrolling in a Part D plan, make sure to check the plan’s formulary. Look for the medications you are taking to be sure they are covered and to find out what your copay will be.
Most oral cancer medications will fall under Part D. However, if your doctor prescribes the drug and gives it to you within 48 hours of a cancer treatment, it may sometimes fall under Part B. Always ask your doctor if you are uncertain.
Covering the Gaps
Since Medicare Parts A and B have deductibles and coinsurance that normally you would pay for, people have been purchasing Medigap plans for decades. These plans function just as they sound like they would: they fill in the gaps.
Medicare supplement Plan F is the most comprehensive option. It pays all deductibles and the 20% that you would normally owe. Many people refer to Plan F as first dollar coverage for this reason. It certainly does offer some peace of mind to people undergoing cancer treatment. You will not have to worry about any big balance bills arriving in your mailbox.
Medicare supplements Plan G and N are also popular. Both of these plans will have lower premiums than Plan F. This is because you agree to pay the Part B deductible, and on Plan N, you take on some copays for doctor visits, ER visits, and excess charges.
If you are entering Medicare while undergoing cancer treatment, do not worry about pre-existing conditions. You will have 6 months from your Part B effective date to enroll in any Medigap plan. They cannot turn you down during this period or ask you any health questions.
Medicare Advantage Plans
Some people enroll in a Medicare Part C Advantage plan instead of Medigap and a drug plan. These plans pay instead of Medicare. This coverage works differently than Medigap. Most Advantage plans have a network of doctors, such as an HMO or PPO network. You’ll want to make sure your oncologist for other important providers are in the network before you enroll.
Advantage plans often have lower premiums than Medigap plans, but you’ll have some cost-sharing on the back end. There might be a $10 copay to see a primary care doctor and a $40 copay to see a specialist. You might pay 20% for an MRI. Each plan’s summary of benefits will outline your cost-sharing so you’ll know what to expect.