‘unlimited’ Cancer Costs: The Medicare Part D Dilemma
Sharon Worcester
May 27, 2022
Learning that a family member has cancer can be devastating enough. Waiting to find out whether a loved one can afford their treatment takes the concern to another level.
That was the case for health policy expert Stacie B. Dusetzina, PhD, when her mother was diagnosed with metastatic breast cancer.
“There is this period where you are waiting to learn more about the cancer type and treatment options, and, of course, what might be covered by your health plan,” Dusetzina, an associate professor at Vanderbilt University Medical Center, Nashville, Tennessee, told Medscape Medical News. “Knowing as much as I do about coverage for prescription drugs in Medicare Part D, I was worried we would be in a situation where my mom had to spend over $15,000 out-of-pocket every year for one of these drugs.”
That $15,000 would have taken a large chunk of her retirement income and could make treatment unaffordable down the line.
This situation is hardly unique.
Many patients with cancer who rely on Medicare Part D face an impossible choice: “Your money or your life,” Dusetzina said.
In a recent perspective in the New England Journal of Medicine, Dusetzina detailed how subtle variations in people’s cancer type can have major implications for their out-of-pocket drug costs.
“This is ARBITRARY and INEQUITABLE,” she added.
Take the drug costs for two similar patients with breast cancer.
Fortunately, that wasn’t the case for Dusetzina’s mother.
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Does Medicare Cover Cancer Screenings
Medicare covers 100% of specific cancer screenings as a preventive health service as long as your doctor accepts Medicare assignment.
Including:
- A mammogram every year for women over 40
- Pap smears and pelvic exams to screen for cervical and vaginal cancer, once every 24 months, or once every 12 months for women who are at increased risk
- Colorectal cancer screening, including a colonoscopy every ten years for anyone over 50, and additional screenings for people at increased risk
- Annual lung cancer screenings for smokers or former smokers aged 55-77 whose doctors order a screening
- Prostate cancer screening once a year for men over 50
Does Medicare Cover Chemotherapy Pills
Though prescription drugs are not covered by Medicare Part A or Medicare Part B , most Medicare Advantage plans offer prescription drug coverage.
Some of the prescription drugs that may be covered by a Medicare Advantage plan include:
- Medications for chemotherapy only available to be taken by mouth
- Anti-nausea drugs
- Pain medication and other prescription drugs used in the course of your cancer treatment
Many Medicare Advantage plans also offer benefits such as dental, vision and hearing coverage, which Original Medicare doesnt cover.
Plan benefits and availability can vary based on where you live.
Find Medicare Advantage plans in your area
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Avoiding Minimizing Or Delaying The Coverage Gap
There are some ways you can avoid or delay entering the gap, and save money on drug costs while in the gap:
- You might be able to switch to generic drugs or other less costly drugs. Ask your doctor about generic alternatives that work just as well. Even though many cancer drugs do not have generics, the savings in non-cancer drugs may help a lot.
- Keep using your Medicare drug plan card, even if your drug expenses fall in the coverage gap. Using your drug plan card ensures that youll get the drug plans discounted rates and that the money you spend counts toward your catastrophic coverage.
- Look into Patient Drug Assistance Programs that may be offered by the company that makes the drug you take.
You can find out more about saving money by using mail-order pharmacies, generic, or less-expensive brand-name drugs online at www.medicare.gov.
Copayments Coinsurance And Deductibles
Depending on the coverage you have, you’ll likely be required to pay a portion of your treatment costs in copayments, coinsurance and deductibles.
- Copayment: A predetermined and fixed dollar amount that beneficiaries may pay for specific treatments
- Coinsurance: The percentage of treatment costs that a beneficiary must pay out-of-pocket
- Deductible: An annual amount that beneficiaries are required to pay on their own before coverage begins
The best way to determine exactly what your plan will cover is by speaking with your plan administrator or your health care provider.
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How Do The Parts Of Medicare Cover Cancer Treatment
The amount that Medicare will cover for cancer treatments can vary based on the type of cancer you have and the type of treatment plan prescribed by your doctor.
The type of policy you have can also play a role in your Medicare cancer coverage and how much you’ll have to pay out-of-pocket.
There are four parts of Medicare, referred to as Part A, Part B, Part C and Part D.
Does Medicare Cover Radiation For Cancer Treatment
Radiation in small doses can be used in x-rays, such as x-rays of your teeth. Radiation in high doses can kill cancer cells and shrink tumors, according to NIH. Radiation cancer treatment damages the DNA of cancer cells, making them unable to divide and killing them. External beam radiation therapy treats a specific part of your body. Internal radiation therapy could be a local treatment or systemic therapy, traveling in the blood to tissues throughout the body. Medicare Part A generally covers radiation cancer treatment for hospital inpatients. Medicare Part B covers radiation therapy for outpatients of patients in freestanding clinics. Medicare Advantage plans also generally cover radiation.
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What Infusion Drugs Are Covered By Medicare Part B
Infusion drugs are those that are administered intravenously through a needle or catheter. To be covered by Medicare Part B, the drugs must be non-oral or biological, administered through an IV or applied under the skin for a period of at least 15 minutes. The drugs must be considered reasonable and necessary and not self-administered.
Some common infusion drugs that may be covered by Medicare Part B include:
If you would like to check Medicare Part B coverage of a specific drug, call 1-800-MEDICARE and speak to a representative concerning your medications and the coverage requirements surrounding it.
Does Medicare Cover Hifu Treatment
High-intensity focused ultrasound, or HIFU treatment, is commonly prescribed as an alternative treatment for prostate cancer. This treatment uses highly focused ultrasound to locate and destroy cancer cells. Many doctors prefer this as an initial treatment because it’s non-invasive and it doesn’t harm healthy tissue or have severe adverse side effects like radiation and chemotherapy often do.
Most Medicare plans do cover a portion of HIFU treatment. As an outpatient procedure, it falls under Medicare Part B. If hospitalization is required during treatment, that portion of the costs would typically be covered under Medicare Part A.
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How Much Does Medicare Pay For Cancer Treatment
If your chemotherapy services are covered under Medicare Part B, you typically pay 20 percent coinsurance of the Medicare-approved amount .
If youre an inpatient and receive chemotherapy while in the hospital, your treatment may be covered by Medicare Part A rather than Part B.
The specific amount youll owe for inpatient chemotherapy may depend on type of inpatient facility, how long you stay and whether your doctor accepts assignment.
We recommend asking your health care provider for specific cost information.
Medicare Part B Drugs: Cost Implications For Beneficiaries In Traditional Medicare And Medicare Advantage
In the face of rising prescription drug costs, a large majority of the public supports federal efforts to lower drug spending. In his 2022 State of the Union address, President Biden urged Congress to pass legislation to rein in drug costs. In November 2021, the House of Representatives passed the Build Back Better Act , which includes several provisions that would lower prescription drug costs, but the Senate has yet to take action on this legislation. Proposals included in the BBBA would allow the federal government to negotiate the price of some drugs covered under Medicare Part B and Part D require drug companies to pay rebates to the federal government when annual increases in drug prices for Medicare and private insurance exceed the rate of inflation cap monthly insulin costs for people with Medicare and private insurance and cap Medicare beneficiaries out-of-pocket drug spending under Part D .
In the first part of this analysis, we examine Medicare claims data for 2019 to assess cost-sharing liability for Part B drugs for beneficiaries in traditional Medicare . In the second part of our analysis, we use Medicare Advantage benefit design data for 2022 to examine the range in cost-sharing amounts at or below 20% coinsurance charged by Medicare Advantage plans for in-network Part B drugs. We also analyze variation in cost-sharing amounts for out-of-network Part B drugs charged by plans that provide out-of-network coverage.
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Fees For Services In Hospital
If youre treated as a public patient, Medicare pays for your treatment, medicines and care while you are in hospital, and for follow-up care from your treating doctor in an outpatient clinic.
For private patients in a public or private hospital, Medicare pays 75% of the Schedule fee for services provided by your doctor. If your doctor charges more than the Schedule fee, your health fund may pay the gap fee or you may have to pay it as an out-of-pocket cost. You will also be charged for hospital accommodation, operating theatre fees and medicines. Private health insurance may cover some or all of these costs, depending on your policy. You may have to pay an agreed amount of the hospital fee , depending on the type of hospital cover you have. Fees charged by private hospital emergency departments are not covered by Medicare or private hospital cover.
Before being admitted to hospital as a private patient, ask:
- your doctor for a written estimate of their fees , who else will care for you , and how you can find out what their fees will be
- your private health fund what costs they will cover and what youll have to pay some funds only pay benefits for services at certain hospitals
- the hospital if there are any extra treatment and medicine costs.
Health funds make arrangements with individual doctors about gap payments. Choosing to use the doctors and hospitals that take part in your health insurers medical gap scheme can help reduce out-of-pocket costs.
Medicare Part A And Cancer Benefits
If you have cancer and are hospitalized, Medicare Part A will cover a portion of your medically-necessary cancer-related services and treatments, according to Medicare Coverage of Cancer Treatment Services, a guide created by the Centers for Medicare & Medicaid Service . These services and treatments include:
- In-patient hospital stays
- Cancer treatments received while inpatient
- Some clinical research study costs
- Hospice care
Medicare Part A also provides coverage related to breast prostheses that are surgically implanted after a mastectomy , home health care services related to rehabilitation, and skilled nursing facility care.
Medicare Part A also provides coverage related to breast prostheses that are surgically implanted after a mastectomy , home health care services related to rehabilitation, and skilled nursing facility care.
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Understanding Cancer Risk In The Elderly
The studys authors say that there are many factors that can potentially increase an elderly persons risk of developing cancer. For instance, exposure to chemical agents, radiation, and smoking tobacco can all play a role. There are several health conditions that can raise a persons cancer risk as well, and they include:
- Diabetes: Linked to cancers of the breasts, colon, and pancreas
- Obesity: Linked to cancers in the esophagus, pancreas, thyroid, gallbladder, colon, rectum, breasts, endometrium, and kidneys
- Hepatitis C: Increases risk of hepatocellular carcinoma, a cancer that begins in the liver
Cancer Drug Coverage Under Medicare Part D
Medicare Part D covers prescription medications and can either be purchased on its own to add more coverages to Original Medicare, or sometimes it is a benefit that is lumped in with an all-in-one type of Medicare Advantage Plan. If you have it as part of Original Medicare, the ACS says that it is still more likely that your medications will be covered under Part B instead. This is because the main cancer-related drugschemotherapy and anti-nausea medicationsare administered via IV, which classifies them as an outpatient service. On the other hand, if you take your cancer drugs orally, these are typically covered under Part D, the actual Medicare prescription plan. Additionally, if youre new to the Medicare prescription drug plan and it does not cover the medication youre currently taking as a result of having cancer, the CMS says that the plan must let you get a 30-day temporary supply of the prescription . This gives you time to work with your healthcare provider to find a drug that is just as effective and also covered under your new plan.
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For Breast Cancer Medicare Covers Two Different Mammograms
- A screening mammogram once every 12 months at no cost if your doctor accepts Medicare assignment for women with Medicare age 40 or older.
- A diagnostic mammogram if medically necessary. Frequency will vary based on your individual situation. Medicare will cover 80 percent of the cost of this type of mammogram, while you will be responsible for the other 20 percent and the Part B deductible.
Does Medicare Cover Cancer Medications
Part B covers some cancer medications, but others are not included unless you have a Part D prescription drug plan. Cancer drugs can be costly. This means that Medicare prescription drug coverage is an essential part of your cancer protection strategy.
Part B covers 80% of the cost of intravenous cancer treatment and anti-nausea drugs. It also includes oral versions of these drugs if your doctor could have given you an intravenous dose but decided to provide you with a pill instead, and the medicine is taken within 48 hours of your cancer treatment.
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Part D covers cancer drugs that are not covered by Part B, including anti-nausea medications that are only available in pill form, injections that you give yourself, and medicines designed to prevent cancer from recurring.
Your Part D prescription coverage offsets the high cost of cancer drugs. Your copays or coinsurance may be far less than what you would pay if you didnt have drug coverage at all.
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For Lung Cancer Medicare Part B Will Cover The Following Screening:
A Low-Dose Computed Tomography if all of the following conditions are met:
- Youre over age 55
- You get a written order from your doctor
- Youre either a current smoker or have quit within the last 15 years
- You have a history of smoking an average of one pack or 20 cigarettes per day for 30 years
- You dont exhibit any signs or symptoms of lung cancer
Medicare And Cancer Treatment Coverage
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In 2009, just over 50 percent of all cancers occurred in individuals 65 years old or older, according to research published in the American Journal of Preventive Medicine. By the year 2030, though, that number is expected to grow to 70 percent. What is the cause of this level of increase?
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Medicare Is Likely To Pay For Anticancer Drugs
The US Congress looks set to provide cover for anticancer drugs under Medicare, the federal health insurance programme for Americans aged over 65.
A bill currently before the house looks likely to be passed this year. According to law makers and lobbyists, this would be a first step towards a prescription drug benefit for Medicare subscribers.
A compromise on drugs to treat cancer would help many elderly Americans who must often choose between expensive prescription drugs and groceries. More than a fifth of the 40 million Medicare beneficiaries receive some type of cancer treatment each year.
The bill that Congress is likely to pass would provide coverage for all oral anticancer drugs and would authorise payment for a wide range of drugs not currently covered by Medicare. These include tamoxifen , imatinib mesylate , and cyclophosphamide .
The Access to Cancer Therapies Act of 2001, introduced to Congress by Deborah Pryce, a Republican representative from Ohio, has 258 cosponsors. The comparable Senate bill, introduced by Democratic senator John Rockefeller of West Virginia and Republican senator Olympia Snowe of Maine has 34 cosponsors, including Democratic senator Tom Daschle, the majority leader.
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What Is The Difference Between Part B And Part D Drugs
Medicare Part B covers drugs that usually are not self-administered. That is, they are given by a doctor or other health care professional in a doctors office, other outpatient facility or at home by a home health aide or caregiver. These drugs are generally administered by infusion or injection.
Medicare Part D covers drugs that are prescribed by your doctor and then filled at a pharmacy and are self-administered. These can include both oral and injectable drugs.
As mentioned above, Part B is one of the two parts of Original Medicare . Original Medicare is publicly funded and provided by the federal government. Medicare Part D prescription drug plans and Medicare Advantage plans that include drug coverage are sold by private insurance companies, though they are regulated by the Centers for Medicare & Medicaid Services .
Medicare Part D coverage can exist as a standalone plan or as part of a Medicare Advantage plan .
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