Medicare Coverage Of Cancer Treatment
This presentation describes how Medicare covers one of the most common issues facing our nation’s senior population, cancer. As the 2nd most common cause of death in the United States, 40% of men and 39% of women will develop cancer in their lifetime, and 80% of new cancer cases are diagnosed in people aged 55 and older (according to the American Cancer Society “Cancer Facts and Figures 2020”).
Along with a healthy and active lifestyle, early detection is key to beating a cancer diagnosis and going into remission. Medicare Part B covers many preventive tests for cancer, let’s dig into each kind, what’s covered, and how often.
Cervical & Vaginal Cancer Screening
Covers Pap tests and pelvic exams to check for cervical and vaginal cancers. Medicare covers these screening tests once every 24 months. If you’re at high risk for cervical or vaginal cancer, or if you’re a child-bearing agent and had an abnormal Pap test in the past 36 months, Medicare covers these screenings once every 12 months.
Part B also covers Human Papillomavirus (HPV) tests (as part of a Pap test) once every 5 years if you’re age 30-65 without HPV symptoms.
You pay nothing for the lab Pap and the lab HPV with Pap test, Pap test specimen collection, and pelvic exam if your doctor or other qualified healthcare provider accepts assignment.
Colorectal Cancer Screenings
Multi-target stool DNA tests – Medicare covers this at-home multi-target stool DNA lab test once every 3 years if you meet all of these conditions:
• You’re age 50-85
• You show no symptoms of colorectal disease
• You’re at average risk for developing colorectal cancer
You pay nothing for this test if your doctor or other qualified healthcare provider accepts assignment.
Screening Barium Enemas – Medicare covers this test if you’re 50 or older. When this test is used instead of a flexible sigmoidoscopy or colonoscopy, Medicare covers the test once every 48 months if you’re age 50 or older and once every 24 months if you’re at high risk for colorectal cancer. You pay 20% of the Medicare-approved amount for your doctor’s services. In a hospital setting, you also pay a copayment. The Part B deductible doesn’t apply.
Screening Colonoscopies – Medicare covers screening colonoscopies once every 24 months if you’re at high risk for colorectal cancer. If you aren’t at high risk for colorectal cancer, Medicare covers the test once every 120 months, or 48 months after a previous flexible sigmoidoscopy.
There’s no minimum age requirement. You pay nothing for this test if your doctor or other qualified healthcare provider accepts assignment. However, if a polyp or other tissue is found and removed during the colonoscopy, you may pay 20% of the Medicare-approved amount of your doctor’s services and a copayment in a hospital setting. The Part B Deductible doesn’t apply.
Screening Fecal Occult Blood Tests – Medicare covers screening fecal occult blood tests once every 12 months if you’re 50 or older, if you get a referral from your doctor, physician assistant, nurse practitioner or clinical nurse specialist. You pay nothing for this test if your doctor or other qualified healthcare provider accepts assignment.
Screening Flexible Sigmoidoscopies – Medicare covers screening flexible sigmoidoscopies once every 48 months for most people 50 or older. If you aren’t at high risk, Medicare covers this test 120 months after a previous screening colonoscopy.
You pay nothing if your doctor or other qualified health care provider accepts assignment. If a screening flexible sigmoidoscopy results in the biopsy of removal of a lesion or growth during the same visit, the procedure is considered diagnostic and you may have to pay a coinsurance and/or a copayment, but the Part B deductible doesn’t apply.
Lung Cancer Screenings
Medicare covers lung cancer screening with Low Dose Computer Tomography (LDCT) once each year if you meet all of these conditions:
• You’re age 55-77
• You don’t have signs or symptoms of lung cancer (asymptomatic)
• You’re either a current smoker or have quit smoking within the last 15 years.
• You have a tobacco smoking history of at least 30 “pack years” (an average of one pack per day for 30 years).
• You get a written order from your doctor.
You pay nothing for this service if your doctor accepts assignment. Before your first lung cancer screening, you’ll need to schedule a lung cancer screening counseling and shared decision-making visit with your doctor to discuss the benefits and risks of lung cancer screening. You and your doctor can decide whether lung cancer screening is right for you.
Medicare covers one baseline mammogram if you’re a woman between ages 35-39, screening mammograms once every 12 months if you’re a woman age 40 or older, diagnostic mammograms more frequently than once a year if medically necessary. You pay nothing for the screening test if your doctor or other qualified health car provider accepts assignment. You pay 20% of the Medicare-approved amount for a diagnostic mammogram, and the Part B deductible applies.
Prostate Cancer Screenings
Medicare covers digital rectal exams and prostate specific antigen (PSA) blood tests once every 12 months for men over 50 (beginning the day after your 50th birthday.)
• Digital Rectal Exam: you pay 20% of the Medicare-approved amount for a yearly digital rectal exam and for your doctor’s services related to the exam. The Part B deductible applies. In a hospital outpatient setting, you pay a copayment.
• PSA Test: you pay nothing for a yearly PSA blood test. If you get the test from a doctor that doesn’t accept assignment, you may have to pay an additional fee for the doctor’s services, but not for the test itself.
Medicare will now cover genetic testing for beneficiaries if:
• You have recurring, relapsed, refractory, metastatic, or advanced stage III or IV cancer
• You have not used the same genetic test for the same cancer diagnosis previously
• You decided to seek further treatment such as chemotherapy and radiation
• You have signs or symptoms of a cancer that can be verified with diagnostic testing
• You have a first-degree relative who has a known genetic mutation
Genetic testing is used in genetic therapy, which targets the specific cancer down to a DNA level so treatment can be specialized for each beneficiary.
Medicare also covers other medically necessary diagnostic testing like x-rays, CT scans, MRIs, biopsies and blood tests.
Treatment Options & Coverage
A comprehensive will include one of more of the following, all of which can be covered by Medicare:
• Surgery – may be recommended for removing cancerous tumors
• Chemotherapy – involves chemical given orally or intravenously to kill cancer cells and stop cancer from spreading
• Radiation – uses intense beams of energy to kill cancer cells
• Hormone Therapy – uses synthetic hormone and hormone blockers to target cancers that use hormones to grow
• Immunotherapy – use your body’s immune system to attack cancer cells
• Genetic Therapy – these newer therapies typically deliver a virus to a cancer cell that will target and help destroy it.
Part A Coverage
• Inpatient hospital stays
• Blood work
• Diagnostic testing while inpatient in a hospital
• Inpatient surgical procedures to remove a cancerous mass
• Some costs of clinical research studies while inpatient
• Surgically-implanted breast prostheses after a mastectomy while inpatient
Part B Coverage
• Visits with your primary care physician, your oncologist(s), and other specialties
• Intravenous and some oral chemotherapy
• Radiation treatments in an outpatient facility
• Diagnostic tests
• Outpatient surgeries
• Some costs of clinical research studies at an outpatient facility
• Breast prostheses after a mastectomy if the surgery takes place in an outpatient setting
• A second opinion for surgery (that isn’t an emergency)
• A 3rd opinion if the first and second opinions are different.
Part D Coverage
• Prescription drugs for chemotherapy, only if taken by mouth
• Anti-nausea drugs
• Other prescription drugs use in the course of your cancer treatment, like pain medication
• NOTE: prescriptions must be included in the beneficiary’s formulary to be covered. Beneficiaries may need to go through the formulary exception process to have outpatient drugs covered by their Part D plan.
Medicare does not cover “alternative” or holistic therapy, including:
• Dietary changes
• Natural Extracts
Medicare does not cover experimental, non-FDA approved treatment.
Costs of Cancer
Beneficiaries should make sure they are going to providers that accept Medicare Assignment! That way, whatever Medicare deems as the approved amount is payment in full, and can help clients avoid thousands in out of pocket costs.
Doctors that do not accept Medicare assignment can bill for Excess Charges, which is 15% above Medicare’s approved amount for services. Also, Medicare doesn’t pay those doctors directly for services, they will pay the client and the client will be responsible for paying the provider. Many centers of excellence, like Mayo, Moffitt, MD Anderson and Johns Hopkins, bill for excess charges.
The average annual out-of-pocket costs for cancer treatment for Medicare beneficiaries ranges from $2,116 to $8,225 depending on what type of Medicare insurance they have.
Part A and Part B costs are what they are, paying special attention to the 20% for chemotherapy and the possibility of having to pay excess charges and make the billing/payment process confusing for the client.
Medicare Advantage clients are at the highest risk for out of pocket exposure. Outside of those with Medicare and Medicaid on a Dual SNP plan, every Medicare Advantage plan in every county from every carrier is going to have a 20% coinsurance for outpatient chemotherapy, and with out of pocket maximums moving up to as high as $7,700 for 2021 plan year, clients are almost guaranteed to reach that number if they are diagnosed with cancer.
Medicare supplement beneficiaries are usually in good shape for cancer treatment, unless their plan doesn’t cover Part B Excess charges and they go to a provider that doesn’t accept Medicare assignment.
All Medicare beneficiaries have to deal with the out of pocket costs of prescription drugs they get from their local pharmacy, with many cancer and immunotherapy drugs falling into the Tier 4 category.
First diagnosis cancer plans are a great way for beneficiaries to get further financial protection should you experience a cancer diagnosis.