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.
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.
Medicare Supplement Plans And Cancer
Medicare Supplement plans work secondary to Original Medicare, and how much they cover depends on the plan that you choose. For instance, Medicare Supplement Plan G covers all of the Medicare-approved copays or coinsurance, so you dont pay out-of-pocket each time you visit the doctor. Because of this, its easy to predict your costs. As long as Medicare pays, your supplement plan will pay as well, and you can use them anywhere that accepts Medicare. Medicare Supplement plans dont pay for your prescriptions, because Original Medicare doesnt cover them.
When Cant A Medicare Advantage Plan Deny Coverage Or Charge Extra Fees
If youre eligible for Medicare, and you want to enroll in a Medicare Advantage plan, heres some good information to know. A Medicare Advantage plan cant deny you coverage if you have a health problem. Thats assuming that you live within the plans service area and are enrolled in Medicare Part A and Part B when you apply for the plan.
- Generally, Medicare Advantage plans cant refuse to cover your medical services once youre enrolled, as long as you follow plan rules. For example, the plan typically cant deny coverage of your health condition.
- In most cases, Medicare Advantage plans cant charge you more than Original Medicare would cost you for certain services, such as skilled nursing facility care, dialysis, or chemotherapy.
- If a plan has agreed to treat you through an advanced determination of coverage, the plan cant decide later to deny you coverage if it finds that your condition isnt medically necessary.
What if you have end-stage renal disease ?
Beginning January 1, 2021, people with ESRD can enroll in Medicare Advantage plans. End-stage renal disease is permanent kidney failure requiring regular dialysis or a kidney transplant.
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The Real Disadvantage Of Medicare Advantage Plans
In Understanding Medicare in 4 Easy Steps, we outline how to determine if Medicare Advantage or Original Medicare and a Medigap plan is the best option for you. To paraphrase, we suggest that theres a single fundamental difference that helps most people make the right choice. In fact, the bulk of the pros and cons of Medicare Advantage plans take a back seat to this one issue.
The difference is this. With Original Medicare and supplemental Medicare insurance, you pay the bulk of your major medical costs upfront through monthly insurance premiums. Doing so lets you budget your health care costs.
When you have Medicare Advantage, you pay most of your health care costs when you use services. For this reason, it is very difficult to budget your health care costs. And this is the primary disadvantage of Medicare Advantage plans. If you fit into one of the five categories above, this wont be much of a disadvantage. If not, it could put you in a world of hurt.
How To Apply For Medicare When You Have Cancer
Caroline Edlund, LCSW-R, is the Online Support Group Program Director at CancerCare. She provides supportive counseling and resources to people coping with cancer and people who have experienced the loss of a loved one.
Enrolling in Medicare can seem like a daunting process, especially if you have cancerso much so that you may be tempted to put off the application or even give up on it entirely. However, this can lead to serious long-term consequences that affect your cancer care coverage and finances.
With a little patience and preparation, you can successfully navigate the Medicare enrollment process. Here are 5 tips to keep in mind.
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How Much Does Medicare Cover For Cancer Treatment
While Medicare covers a significant portion of cancertreatment bills, it doesnt pay for them in full. Medicare Part A and Medicare Part B togetherare referred to as Original Medicare, and they represent your inpatient andoutpatient coverage. They each usually pay for up to 80% of your medical bills,after deductibles and copays. In addition, while Original Medicare covers mostmedications that youre given in a medical setting, Original Medicare typicallydoesnt cover your prescription medications.
In order to help control your out-of-pocket expenses, youhave several options:
- Medicare Supplement Plans
- Medicare Part D Prescription Drug Plans
Does Medicare Cover Chemotherapy
Medicare Part A and/or Part B typically cover chemotherapy for beneficiaries who have cancer and receive treatment from a doctor who accepts Medicare assignment.
Medicare Advantage plans also cover chemotherapy for qualified beneficiaries. Most Medicare Advantage plans also cover prescription drugs, such as oral chemotherapy cancer drugs.
Original Medicare does not typically cover prescription drugs.
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What About The Medicare Advantage Give Back Benefit
The give-back benefit allows some Medicare Advantage plans to offer plan members a rebate on their monthly Medicare Part B premium. Beneficiaries with a give-back plan receive the benefit through Social Security. No direct payments are allowed.
The technical term for the benefit is Medicare Part B premium reduction. When you enroll in one of these plans, the insurance carrier pays some or all of your premium. In the evidence of coverage document the plan is required to provide, you will find a section titled Part B Premium Buy-Down. This is where you will find the amount the plan contributed towards your Part B premium.
Plans with a give-back benefit are becoming more popular, but they are still not widespread. The largest companies offering these plans include Aetna, Cigna, and Humana. Give-back amounts range from as little as $.10 to as much as the full, standard Part B premium.
If you pay your own Part B premium you are eligible for a give-back plan. If you have full or partial Medicaid, including aid through a Medicare Savings Program, you are not eligible.
What Services Does Medicare Cover
Medicare has an extensive list of cancer-related treatmentsthat it covers as long as your doctor says that its medically necessary, andits performed within Medicares guidelines. If you have a Medicare Supplementplan, your plan will pay its usual amounts as long as Medicare pays first. Ifthe item or treatment isnt covered by Medicare, the Medicare Supplement planwont pay either.
If you have aMedicare Advantage plan, youll need to check to see whats covered accordingto your carrier. Medicare Advantage plans are forms of private insurance, socarriers may have different guidelines on the treatments they offer, and thequalifications you have to meet.
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Medicare Advantage Coverage Of Cancer
Medicare Advantage plans cover the same Part A and B services as Original Medicare. However, how you access your benefits and what you pay for services will be different.
Heres how they work:
Most plans have an HMO or PPO network of providers. Youll seek care within the network to get the lowest copays. Sometimes the oncologist or hospital you wish to see may not be in the plans network.
With Medicare Advantage plans, you have cost-sharing or copays for treatment as you go along. Some cancer services under Medicare Advantage plans require up to 20% coinsurance from you. You pay a percentage of the cost of that treatment.
We see many plans where your cost-sharing for chemotherapy and radiation will be as much as 20%. You will pay this until you reach the plans Out-of-Pocket Maximum. That maximum can be as high as $7550 per calendar year in the network in 2021, and even higher out-of-network.
Lets check out an example:
Doug is undergoing radiation for prostate cancer. His Medicare Advantage plan requires him to pay a 20% coinsurance for his radiation treatments. While he is getting treatment, he also has twice monthly appointments with his oncologist at which he pays a $50 copay for a specialist visit.
He pays this 20% radiation cost and all of his doctor copays until he reaches $7550 out of his own pocket. Then the plan covers 100%.
Be aware of this before you enroll in a Medicare Advantage plan.
Heart Failure And Cardiovascular Disorders
- If youre considering a Medicare Advantage plan, find out if there are any SNPs in your area. Some of the most common plans focus on cardiovascular disorders and heart failure. Anthems Heart SNPs, for example, help people manage congestive heart failure through medications, fluid retention control, nutrition counseling and an exercise program. Members receive a personalized care plan from a team that includes a nurse practitioner, primary care physician, nutritionist, registered dietitian and exercise coach, says Alex Furman, vice president of Medicare duals strategy at Anthem.
Some plans include additional benefits, such as cardiac rehabilitation, medication management, nutrition counseling, classes and materials, and a smoking cessation program, Furman says.
- Check a Medicare Advantage plans Evidence of Coverage for details about any extra benefits you might qualify for. Aetna is participating in a CMS program called the Value Based Insurance Design model, which allows insurers to provide extra benefits within some of their regular Medicare Advantage plans. Aetna is offering benefits for people with congestive heart failure, including no copayments for cardiology visits and certain heart medications. The insurer is expanding the number of plans that will offer these benefits in 2022.
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What About Other Cancer
There are a lot of costs associated with cancer, and unfortunately, about 42% of them are indirect costs.
Translation: Medicare wonât pay for nearly half the costs associated with a cancer diagnosis.
Weâre talking about things like transportation to and from specialty hospitals, hotels and lodging while there, loss of income if you were working, clothing and hair pieces, and even experimental medications and trial drugs that could save your lifeâ¦ Medicare wonât pay for them.
Many cancer patients travel out of state to receive higher quality care from specialized cancer centers. In fact, patients treated at one of a handful of specialized cancer centers had a 9% higher survival rate over 5 years compared to patients treated at community hospitals.
On top of that, the Sloan Kettering researchers found that patients treated at these hospitals had a 10% lower chance of dying in the first year than did patients who were treated at other facilities including community hospitals.
Itâs in your best interest to travel, and thatâs expensive! Common travel costs include:
- Restaurants/Fast food
So, how can you plan for potential cancer costs even if you have Medicare and a Medicare Supplement?
Can Medicare Supplement Plans Help
Yes and no. Medicare supplement plans, also known as Medigap plans, are plans that help to cover your out-of-pocket costs under Original Medicare. Rather than covering health care directly, Medigap plans will cover things like your Part A and Part B coinsurance and copayment fees.
Although this wont actually give you more medical coverage, it can end up being a big help for those undergoing cancer treatments, which are often costly. There is a wide variety of Medigap plans to choose from, and they each have their own unique benefits. These plans are private, which means they will vary in cost. However, the coverage for Medigap plans is standardized.
Although they arent a good fit for everybody, everyone with Medicare should at least consider Medigap plans, as they can be a big help to some.
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 Chemotherapy Drugs
If youre a cancer patient in a hospital, outpatient clinic, or doctors office, Medicare typically covers chemotherapy drugs and treatment, as long as its medically necessary.
If your chemo is administered through an IV at a doctors office or as an outpatient, it may be covered by Part B. If its administered orally or IV in a hospital or as an inpatient, it will likely be covered by Part A.
Chemotherapy, which can be administered orally through pills, capsules or liquids, intravenously through a vein, or by injection into a muscle, is used to treat cancer. There are many types of chemotherapy drugs, and what you receive depends on the type of cancer you have, how advanced it is, and whether or not you have other health issues or risk factors.
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Consider Which Medicare Plan Meets Your Needs
When reviewing Medicare coverage plans, its important to consider how your choices may impact your cancer care and finances. For instance, choosing original Medicare allows you to see any doctor you want, but can bring significant out-of-pocket costs. However, a Medicare Advantage plan limits your choice of doctors but tends to be less expensive. Consider whether you are willing to switch doctors. Be sure to ask any doctor you plan on seeing what plans they accept.
If you regularly take prescription medication, be aware that original Medicare does not offer drug coverage. You will need to buy Part D or choose from among the Medicare Advantage plans for that type of coverage. However, not all Advantage plans include drug coverage, and costs can be very different from plan to plan. Whatever plan you choose, make sure that it meets your health care needs and your budget.
And again, enrollment deadlines matter. While you can generally buy coverage after enrollment deadlines pass, you dont want those permanent penalty fees to be added to your plan costs. So, do your best to meet the deadline dates.
Medicare Advantage And Cancer
If you have Medicare Advantage , this means that youve purchased your Medicare plan from a private insurance company as opposed to getting it directly from the federal government. These types of plans are required to give you the same basic coverages as Original Medicare, but the CMS warns that they can have different rules and costs. Therefore, its important to go through your individual plan so you understand what it says regarding cancer coverage specifically. And if any portion of that policy is unclear, follow up with your policys administrator so you know what is covered and what isnt.
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Medicare Advantage Plans And Cancer
If you select a Medicare Advantage plan, its your primary coverage instead of Original Medicare. Advantage plans have to offer benefits that are at least as good as Medicare Part A and Part B, and some offer extra benefits like prescription drug coverage. Common risks of these plans are that the carrier can choose to decline your treatment even if your provider says that its medically necessary, and the doctors network isnt as broad as Original Medicares. Depending on your plan, you may have high out-of-pocket costs through coinsurance and deductibles.
For Prostate Cancer Medicare Covers The Following Screenings Once Every 12 Months For Men Over 50
A PSA test doesnt cost you anything if you get it done by a doctor that accepts Medicare assignment, but you may pay a fee if the doctor does not. For a DRE, you will pay 20 percent of the Medicare-approved amount for the exam and your physicians services. Youll also be responsible for the Part B deductible. Finally, a copayment will be due if the exam is done in a hospital outpatient setting.
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Do Medicare Advantage Plans Cover Cancer Treatments
Because Medicare Advantage plans must cover everything Original Medicare covers, most of your cancer treatments including radiation, chemotherapy and surgery will be covered.
Most MA plans bundle Part A, Part B and Part D, so you have hospital, medical and prescription drug coverage. The difference is that rules or costs associated with services may be different than Original Medicare.
Is Chemotherapy Covered By Medicare
Whether youâre inpatient or outpatient, Medicare will help cover the costs of chemotherapy.
Medicare Part A will help cover chemo if youâre a hospital inpatient.
If youâre a hospital outpatient or are in a doctorâs office or freestanding clinic, Medicare Part B would help cover chemotherapy.
If you donât have supplemental coverage, the difference between Part A and Part B coverage does matter, because it will directly affect how much you pay.
Medicare Part A Chemotherapy Coverage
If you have cancer and are receiving chemo as a hospital inpatient, Medicare Part A will help pick up the costs.
Your responsibility will be a $1,408 deductible. After you pay that amount, Medicare Part A will do the heavy lifting and cover you.
If you have a Medicare Supplement, your responsibility would be $0.
Medicare Part B Chemotherapy Coverage
If you have cancer and are receiving chemo as an outpatient, Medicare Part B will help pick up the costs.
Your responsibilities will include the Part B deductible as well as 20% coinsurance. Currently, in 2020, the Part B deductible is $198.
If you have a Medicare Supplement Plan F, your costs will be $0. If you have a Medicare Supplement Plan G, your costs will be the Part B deductible, or $198 in 2020. Both Plan F and Plan G pay the 20% coinsurance.
The gray area is the 20% coinsurance. After all, how much does chemotherapy cost, and what would 20% of the total be?
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