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.

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 and 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 leftover 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.