How Medicare Covers Chemotherapy

Throughout our lifetimes, we enroll in health insurance for a variety of reasons. Medicare-ChemotherapyIt gives us access to doctors and provides preventive care and screenings for early detection of medical conditions. There’s no question, however, that the main reason we buy health insurance is to help us pay for major treatment if we are diagnosed with a serious illness such as cancer.

Many people who are new to Medicare or have been recently diagnosed wonder how Medicare covers various cancer treatments, such as chemotherapy. The good news is that Medicare provides extensive coverage of cancer treatment and cancer-related services.

Medigap supplemental coverage is also available to round out that coverage, help pay for your deductibles, and protect you from catastrophic out-of-pocket medical spending. Let’s look at how Medicare’s coverage of chemotherapy and other cancer treatments works:

The Parts of Medicare

Original Medicare has two parts. Part A is your inpatient hospital coverage, and this provides for your hospital room and some skilled nursing care. Part B is your outpatient coverage, which includes physician services, lab work, diagnostic imaging, preventive care, durable medical equipment, and much more. Part D provides prescription drug coverage. Click here for an explanation of Part C.

Although chemotherapy is often administered in a hospital or clinic setting, it generally falls under Part B, since chemotherapy is a treatment administered by a physician. Radiation treatment and some anti-nausea medications are covered under Part B as well, if the doctor prescribes them to you within 48 hours of a chemotherapy session. Otherwise, these would be covered under a Part D drug plan. Click here for a complete chart comparing drugs covered by Parts B vs. Part D.  In terms of chemotherapy coverage, this is how it breaks out:

  Covered by Part B Covered by Part D
Infusion drugs Drugs administered by an implantable infusion pump

 

or

 

Drugs administered by an external infusion pump that you use at home and your local DME contractor covers them under Part B.

Drugs administered by an external infusion pump outside of the home (i.e., in a skilled nursing facility or hospital) and your stay is not being covered by Part A or you do not have Part A.

 

Drugs administered by an external infusion pump that you use in the home, but your Durable Medical Equipment contractor does not cover them under Part B for use in the home.

 

Infusion drugs administered at home without an infusion pump at home. One example of this is an IV push.

Injectable Drugs The drug generally cannot usually be self-administered and your doctor provides and administers the drug to you. You can buy the drug at the pharmacy and it is either administered by your doctor or you administer the drug yourself.
Oral Anti- Cancer Drugs It is an oral anti-cancer drug that was once available only in an injectable form that was covered by Medicare. You or your doctor can administer the drug. It must be used to treat cancer. You use the drug to treat a condition other than cancer.
Oral Anti-Nausea Drugs (antiemetics) Must be related to cancer, used as a full replacement for intravenous treatment, and administered within 48 hours of cancer treatment. It can be administered by yourself or by a doctor. The drug is used for conditions other than cancer.

 

It is used more than 48 hours after cancer treatment or is not a full replacement for intravenous treatment.

Part B has a small annual deductible that you must pay. That deductible is $183 in 2018. Then, Part B pays for 80% of covered services that you receive. You are responsible for the other 20%. This is called your Part B co-insurance. There is no out-of-pocket maximum for Part B, so your expenses could be high.

That is why a Medigap plan can be helpful to pay for that co-insurance and other Medicare-related out-of-pocket costs, such as deductibles and copays. You can find out more information about Medigap plans here.  You may also find a Medicare Advantage plan helpful to lower your out-of-pocket costs.  For more about Medicare Advantage, click here.

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