Medicare covers chemotherapy drugs when a doctor prescribes them. The type of chemotherapy determines which Medicare component provides coverage.
When a person is diagnosed with cancer, their doctor can prescribe chemotherapy drugs that can help fight the condition.
People can take chemotherapy drugs intravenously (IV) or orally. Medicare helps pay for medically necessary chemotherapy.
Medicare is a federal health insurance plan for people 65 and older. Younger people with disabilities may also qualify. There are different parts of Medicare coverage with different benefits:
- Part A. covers care in the hospital.
- Part B includes outpatient services, including doctor’s visits.
- Part D. includes many prescription medications.
Depending on how a person receives chemotherapy drugs and in what setting, it will determine which Medicare components will cover the costs and which out-of-pocket expenses apply.
In this article, we’ll discuss how Medicare covers cancer treatments, chemotherapy, and options a person has to fill any gaps in coverage.
We can use a few terms in this piece that may be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a specified period of time before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of the treatment costs that a person must finance themselves. For Medicare Part B this comes to 20%.
- Additional payment: This is a fixed dollar amount that an insured person pays for certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers cancer treatments with a prescription from a physician who accepts Medicare. Each of the different parts of Medicare covers different aspects of chemotherapy.
Which Medicare components treat chemotherapy
Chemotherapy can be covered by Medicare Parts A, B, or D, depending on the type of chemotherapy.
Medicare Part A includes oral and IV chemotherapy when a person is hospitalized as an inpatient.
Medicare Part B pays for some oral chemotherapy medications and can also cover IV chemotherapy that a person receives in a doctor’s office or detached clinic. Copayments and coinsurance may apply.
Chemotherapy in the hospital
Medicare Part A is hospital insurance and generally covers:
- hospitalization for cancer treatment
- competent nursing care after a 3-day hospitalization
- home care for rehabilitation services
- hospice care
- inpatient breast reconstruction procedures after mastectomy
Some cancer treatments are outpatient services, and in these cases, Medicare Part B can cover the costs. Treatment must be Medicare approved, medically necessary, and related to a person’s cancer treatment.
A person can check what services and treatments are covered by using Medicare’s online tool: Is my test, item or service covered?
Medicare Part D.
If Part B does not pay for a specific drug or treatment, coverage may be available through Part D.
Medicare Part D is a prescription drug plan offered by private health insurance companies. Therefore, coverage options may vary. A person must have Medicare Parts A, B, or both to participate in a Medicare Part D program, and enrollment is not automatic.
The private insurance company determines the drugs covered by the plan. The company publishes one formulary, that’s a list of drugs that the company usually handles. Some Part D plans include both oral and IV chemotherapy medications. Most policies cover:
- oral chemotherapy drugs
- medicines to treat nausea
- prescription medicines used to treat cancer, including pain killers
The companies also put different drugs at specific levels or levels. The level at which the drug is affects a person’s out-of-pocket expenditure.
The out-of-pocket cost can include costs for doctor visits and chemotherapy treatments.
Average out-of-pocket costs vary depending on:
- the type of cancer
- how aggressive the cancer is
- how much and the type of chemotherapy that is prescribed
- whether Medicare covers the recommended chemotherapy
- which Medicare parts a person is holding
Doctors who will accept it order Don’t charge more than the amount agreed by Medicare, and this will help reduce a person’s out-of-pocket expenses.
A study from early 2015 showed the average out-of-pocket cost for cancer treatments with Medicare $ 4,727.00.
The out-of-pocket spend for people getting the same service can range from $ 5,976.00 to $ 8,115.00 by a second
Private insurance companies sell Medicare Advantage plans. The companies must cover the primary benefits of Medicare Parts A and B. However, they can also include Part D and provide additional benefits. Any private company can decide what additional coverage they provide.
All Medicare Advantage plans are different and understanding the rules and fees that may apply is essential. A person can find plans in his or her environment and compare them on the Find a Medicare plan website.
Private insurance companies also sell Medigap plans. These plans help cover additional costs such as:
- own risk
They can also provide additional benefits such as coverage for travel outside of the United States.
A person can find the Medigap policy using the online Medicare tool, Find a Medigap policy that works for you.
A person’s decision to start chemotherapy can be less daunting knowing that treatment will be financially covered.
Together, Medicare Components A, B, C, D, and Medigap help pay some chemotherapy costs.
Medicare Part A pays for many inpatient treatment options. Medicare Part B includes outpatient chemotherapy, both oral and IV.
Medicare Part D can help treat some medications that aren’t covered elsewhere.
Medicare Part C and Medigap can help cover out-of-pocket expenses. Private insurance companies sell them, and as such, different levels of coverage and benefits may apply.
The information on this website may assist you in making personal insurance decisions, but is not intended to provide advice on purchasing or using insurance or insurance products. Healthline Media does not deal with insurance in any way and is not licensed as an insurance company or manufacturer in any US jurisdiction. Healthline Media does not endorse or endorse any third party who may handle insurance business.