Does Medicare Cover Chemotherapy?

Along with the many questions that come after a cancer diagnosis, you may wonder if Medicare will cover the treatments that are needed. If chemotherapy is part of your treatment, Medicare will cover some of your costs under each of its parts. The amount you’ll end up paying out of pocket depends on the Medicare plans you’ve chosen.

Let’s go over what each part of Medicare covers, what isn’t covered, ways to save on treatment costs, and more.

What parts of Medicare cover chemotherapy?

Medicare Part A

Medicare Part A covers costs that are associated with an inpatient hospital stay. This includes the hospital stay itself, as well as the medications and treatments you receive while admitted. Part A also covers a limited stay at a skilled nursing facility after your hospital admission, as well as hospice care.

If you are receiving chemotherapy during your hospital stay, it will be covered by Medicare Part A.

Medicare Part B

Medicare Part B provides coverage for treatments received at outpatient centers. Outpatient centers include your doctor’s office or freestanding clinics. Other things you might need for cancer diagnosis and treatment that are covered through this part of Medicare include:

  • cancer screening and prevention services
  • many different forms of chemotherapy (intravenous [IV], oral, injections)
  • drugs to control certain side effects of chemotherapy (nausea, pain, etc.)
  • medical equipment needed after treatments (wheelchair, feeding pump, oxygen, etc.)

Before coverage kicks in, you’ll need to meet your Part B deductible. After that, Part B will cover 80% of your chemotherapy costs. You will be responsible for paying the remaining 20% of the Medicare-approved amount for your treatments.

Medicare Part C

If you have Medicare Part C, also called Medicare Advantage, you have coverage through a private health insurance company. Part C covers everything that parts A and B cover but may also include prescription drug coverage and other extras.

However, with a Part C plan, you’ll likely need to choose from a list of in- network providers and pharmacies. This will ensure maximum coverage and lower out-of-pocket costs.

Medicare Part D

Medicare Part D covers prescription drugs that you take on your own. Some of the medications covered under Part D that you might need include:

  • chemotherapy, both oral and injections
  • medications for side effects, including nausea, lack of appetite, pain, difficulty sleeping, etc.

Part D does not cover drugs that are given by a healthcare provider while being treated at a healthcare facility. Also, each plan has a different formulary, or list of approved medications, and how much the plan will pay for each one.

If you’ve been prescribed a new drug, contact your insurance provider to see where that medication falls in their tier system and how much you will be required to pay for it after coverage.

Medigap

Medigap plans cover costs that are left over from your other Medicare plans. These include:

  • deductibles for Medicare parts A and B
  • parts B and C copayments and coinsurance
  • copayments from Part D coverage

There is no drug coverage through Medigap plans. This is a supplement to your existing Medicare coverage.

What isn’t covered?

When you are undergoing cancer treatments, it can be hard to know which treatments are covered and which aren’t covered under your Medicare plans. While there may be some variations, like some of the extras in a Part C plan, here are some of the services that generally are not covered under Medicare:

  • in-home caregivers to help with daily activities (bathing, meals, dressing, etc.)
  • long-term care or assisted living facilities
  • room and board expenses while receiving treatments away from home
  • certain treatments given during clinical trials

How much does chemotherapy cost?

The cost of chemotherapy can vary depending on many different factors, like:

  • where you receive it (at the hospital, doctor’s office or clinic, or at home as a prescription)
  • how it’s given (through an IV, oral medication, or an injection)
  • the kind of insurance coverage you have (original Medicare, Medicare Advantage, Medigap)
  • the kind of cancer you have and the type of treatment that is needed to treat it
Part A costs

The 2020 deductible amount for Medicare Part A is $1,408 per benefit period. This should be easily reached if you are doing all of the necessary cancer treatments.

Note that you may have more than one benefit period within a calendar year. A benefit period begins the day you are admitted as an inpatient in a hospital or a skilled nursing facility. The benefit period ends after you have not had any inpatient care for 60 days following that admission. You will owe the deductible amount for each benefit period.

Part B costs

The typical monthly premium for Part B is $144.60. However, the monthly premium may be higher depending on your income.

The 2020 deductible amount for Medicare Part B is $198. After you have met your deductible, you will pay 20% coinsurance on all other services and therapies you receive that fall under Part B coverage.

Part C costs

Medicare Part C costs will vary from plan to plan, depending on the insurance company and the coverage you choose. There will be different copays, coinsurance, and deductibles based on the plan you have. To find out what your deductible is, contact your insurance provider or go to their website to see your out-of-pocket responsibilities.

Many plans have a 20% coinsurance until you reach the out-of-pocket maximum, which must not exceed $6,700. After you’ve reached that amount, you should have 100% coverage. Again, this is different for each plan, so check with your health insurance provider for specifics.

Part D costs

Medicare Part D costs are different for each plan, and each formulary covers different amounts for the chemotherapy drugs you may need. Depending on your type of cancer, there are many generic medications on the market now that are more affordable than brand name options.

Most Medicare Part D plans have a coverage gap, or “donut hole,” which happens when you reach the limit of what your Part D plan will pay for your medications. Part D coverage has several different phases:

  • Deductible. First, you pay your yearly deductible, which for 2020 is a maximum of $435.
  • Initial coverage. This phase is next and will cover up to $4,020 of drug expenses in 2020.
  • Coverage gap. This is the amount you’ll pay out-of-pocket after initial coverage is exhausted, but you haven’t reached the threshold for the next phase, catastrophic coverage.
  • Catastrophic coverage. Once you have spent a total of $6,350 in out-of-pocket expenses in 2020, your catastrophic coverage will kick in. With this coverage, you’ll only pay small coinsurance or copay amounts for your prescriptions through the rest of the year.
Medigap costs

If you are considering a Medigap plan, keep in mind that this is generally more expensive than a Part C plan and does not cover prescription drugs. However, it can provide you some peace of mind that all costs related to your cancer care are covered, without numerous out-of-pocket expenses for every appointment, treatment, and drug.

  • Make sure that all doctors, pharmacies, and treatment facilities that you use participate in Medicare and accept the Medicare-approved cost for the treatments you receive. You can use Medicare’s comparison tool to find participating providers.
  • If you have a Medicare Advantage plan, be sure to choose providers that are in your plan’s network.
  • Check to see if you’re eligible for Medicare’s Extra Help program to help with the cost of prescription drugs.
  • Verify what part of Medicare will be billed for the services you are receiving – this way, you won’t be surprised by a coinsurance bill.
  • Ask your doctor about using a generic drug, if possible.
  • You can appeal a Medicare coverage decision online through the Medicare claims and appeals website.

What is chemotherapy?

Chemotherapy is one of the many forms of cancer treatment. It works by killing cancer cells that spread rapidly in the body.

Chemotherapy can be given alone or combined with other types of cancer treatments. Your doctor will determine what kind of treatment is best for you based on:

  • the kind of cancer
  • the stage of cancer
  • the location(s) of cancer in your body
  • your medical history and overall health
Possible side effects of chemotherapy

Since chemotherapy targets any cells in the body that divide rapidly, it can affect both cancer cells and healthy cells. When it attacks healthy cells, it can cause side effects like:

  • hair loss
  • nausea and vomiting
  • mouth sores
  • fatigue
  • lowered immunity to infections

Your doctor can provide advice to help prevent or manage side effects, which may include:

  • eating certain foods
  • taking medications for nausea and pain

You may be wondering what to expect for your first round of chemotherapy. It can help to talk to someone who has gone through it already.

It may be helpful to find an online support group for your specific type of cancer. You can also search online for local groups with this tool from the American Cancer Society or talk to your cancer center support staff.

The takeaway

If you’re a Medicare beneficiary, chemotherapy is covered under your plan. The extent of coverage will depend on what parts you are enrolled in, and you may have some out-of-pocket expenses.

Out-of-pocket costs can be minimized with a Medigap plan. You. can also compare different Medicare plans to find the best coverage for your situation.

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