Not only does a cancer diagnosis threaten the wellbeing of the patient, but it also stimulates a crucial discussion about how the patient will afford the cost of chemotherapy and what will be covered by insurance. For individuals enrolled in Original Medicare or Medicare Advantage costs will be typically covered for chemotherapy, whether it is given intravenously or by mouth if it is deemed to be medically necessary.
Which Parts of Medicare Pay for Chemotherapy Treatments?
- Original Medicare Part A (Hospital Insurance) pays for inpatient care for those hospitalized by their treating physicians for cancer treatment.
- Original Medicare Part B (Medical Insurance) covers outpatient care for those enrolled in Medicare, including office visits with your doctor for your cancer treatment, diverse types of preventive care and durable medical equipment.
- Medicare Part D, which covers prescription medications taken orally and may cover chemotherapy medications that are not covered under Medicare Part B.
- Medicare Advantage Part C will incorporate the coverage of Medicare Part A and B. It’s likely to have a similar component for chemotherapy prescription drug coverage as well. For more information visit Medicare Advantage Coverage.
Out-of-Pocket Chemotherapy Costs Considerations for Medicare Patients
The amount of out-of-pocket costs that you may have to pay for your cancer treatment under Medicare will vary depending on the following factors including:
- The type and class of cancer that you have, such as prostate cancer, lung cancer, breast cancer or colon cancer.
- The level of aggressiveness the cancer is exhibiting. According to the National Cancer Institute, cancers are graded in aggressiveness by the level of change and differentiation in the cells of the organ involved. For example, G1 cancers are low grade cancers since they are well differentiated, meaning the cells look and organize most like healthy cells. G2 cancers are intermediate grade cancers since they are moderately differentiated, G3 cancers are high grade cancers since they are poorly differentiated and G4 cancers are an even higher grade and more dangerous, the type, amount, and frequency of treatment.
- Your Medicare plan approved treatment that has been physician recommended.
What Is the Medicare Deductible for Chemotherapy?
The Medicare deductible refers to the amount of money that a Medicare enrollee must pay out-of-pocket before Medicare starts to pay for the patient’s chemotherapy treatments.
- For inpatient hospital stays under Part A the benefit period deductible is $1,556 for 2022. This deductible is not an annual deductible but a benefit period that starts the day you are admitted for treatment. So, there is a possibility you would have to pay the deductible more than once in a year considering your benefit period ends if you have not been in inpatient care for 60 days in a row.
- In 2022, the annual Medicare Part B annual deductible is $233.
- Medicare Advantage and Medicare Part D can have variable deduction costs for prescription drugs. The maximum deductible for Part D was $480 in 2022.
What Is the Medicare Coinsurance for Chemotherapy?
Take note the difference between copays and coinsurance. Medicare copays refer to the set rate the patient will pay that typically doesn’t count toward their deductible. Copays are typically related to prescriptions and outpatient doctor visits. Medicare coinsurance refers to the shared cost or percentage of costs the patient will pay out-of-pocket for after they have met their deductible.
- For part A there is no coinsurance for the first 1-60 day benefit period. 61-90 will cost the patient $389 coinsurance per day of each benefit period. For 91 days and beyond it’s $778 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime). Beyond lifetime reserve days the patient will be responsible for paying all related hospitalization costs.
- For Medicare Part B, the coinsurance amount is 20%. For more information visit Medicare Part A and B Costs.
- For Part D coinsurance out-of-pocket costs can vary throughout the year due to changing drug costs and the tiers level that are tied to the patient’s drug. Once the patient and the plan hit a combined cost of $4,430 (in 2022) on drugs the patient will hit the coverage gap (also known as the donut hole. For more information visit The Part D Donut Hole and Medicare Part D Costs.
What Specifically is the Medicare Coverage for Inpatient Chemotherapy?
Medicare Part A pays for qualifying costs that are related to your cancer care while admitted to the hospital. In general, this covers:
- Your entire hospital admission for cancer treatment
- Medically necessary mastectomies and reconstructive surgery relating to cancer treatment
- Skilled Nursing Care in a Skilled Nursing Facility that is medically necessary after a 3-day admission to a hospital to treat cancer
- Rehabilitation Services deemed to be medically necessary after your treatment for cancer
- Care under the Hospice Program for dignified care for cancer patients who are terminal
Medicare Coverage for Outpatient Chemotherapy and Other Services
Medicare Part B covers the cost of outpatient chemotherapy and other outpatient cancer treatments which are medically necessary and approved by Medicare.
In addition, Medicare Part B will cover other types of outpatient services related to your cancer treatment, such as:
- Treatment with intravenous chemotherapy at an outpatient Infusion Center
- Outpatient center radiation treatment
- Oral chemotherapy at an outpatient center
- Surgery at an outpatient center, such as the implantation of a surgical port for the infusion of intravenous chemotherapy
- Walkers or supplemental oxygen
- Outpatient tests and Xray exams such as CT scans to assess the efficacy of chemotherapy treatment
- Feeding tubes and intravenous pumps for nutritional feeding at home
- Outpatient medical research protocol costs
- Breast prosthesis necessary after a mastectomy relating to breast cancer
- Implants of the breast for post mastectomy patients who had their surgery performed at a Medicare approved outpatient surgical center
- Different screening tests conducted on an outpatient basis to determine the success of your cancer treatment or the degree of metastasis of your cancer
- Cancer related pre-operative and post-operative visits to your primary care physician, oncologist, radiologist, and cancer surgeon
Medicare Coverage for Specific Cancer Drugs and Other Treatments
Medicare Part D covers prescription drugs and is administered through private insurance companies. Each drug plan has its own formulary which will determine exactly what outpatient oral chemotherapeutic medications are covered and paid for by Medicare.
Other drugs related to your cancer treatment which Part D Medicare will also cover include medications to treat nausea, and medications used to treat the intractable pain associated with metastatic cancer.