Does Medicare Cover Chemotherapy? Understanding the Costs

If you or a loved one have been diagnosed with cancer and are on Medicare, there are many covered services and treatments to help in your fight against the disease, including surgery and radiation therapy. But does Medicare cover chemotherapy? Yes, Medicare Parts A, B, C, and D can all have a hand in providing coverage for chemo treatments. Your chemotherapy costs will depend on your Medicare coverage and where you receive your treatments, among a few other details.

Being diagnosed with cancer can bring you many more questions than answers. To help, here is GoHealth’s guide to chemotherapy and Medicare.

Not only does Medicare pay for chemotherapy, but it can also help cover several different forms of cancer-fighting medication. Your treatment plan may call for you to receive chemotherapy through an IV line, as a cream, or in pill form. Determining how you receive chemotherapy is the key to figuring out two crucial details:

• Where you receive your chemotherapy
• How much does chemo cost

If you’re enrolled in Medicare and have been diagnosed with cancer, you can rest assured that your coverage will generally help pay for the treatments you need. But knowing how that coverage works is critically important, especially when it comes to your treatment plan. Making sure the two are aligned will help reduce your out-of-pocket costs by maximizing your cost-sharing.

Medicare and chemotherapy: location is everything

As we mentioned above, the type of chemotherapy your treatment plan calls for will go a long way in deciding your coverage and costs. The type of chemo you need determines where you receive it and allows Medicare to figure out how to pay for it.

For example:

1. Outpatient chemotherapy is administered in a hospital, doctor’s office or stand-alone clinic but doesn’t require hospitalization. In this case, Medicare Part B will generally pay. These Medicare beneficiaries can also enroll in Medicare Supplement Insurance (Medigap) to help cover their out-of-pocket costs.
2. Inpatient chemotherapy occurs during hospitalization. In these cases, Medicare Part A often helps cover your costs. Medigap plans can help cover Part A costs.
3. Chemotherapy pills can be taken at home similar to other prescription medications. If you have a prescription for medically necessary chemotherapy, Medicare Prescription Drug Plan (Part D) may be the Part of Medicare that pays for it. Medigap can not be used to help with your Part D copays.

Medicare costs to know

Fighting cancer and living as a survivor can be a long road. Along the way, you’ll come across several different Medicare costs you’ll have to pay. Understanding these costs can help you build a budget and get the most out of your treatment plan. Here are the charges you’ll want to know:

• Deductible: The amount you need to pay before Medicare will pay its portion. There are separate deductibles for Part A, Part B and Part D.
• Premium: the monthly fee you pay for your policy. Medicare Parts A, B and D all have monthly premiums that vary based on your situation. Some insurance companies offer $0 Medicare Advantage (Part C) plans.
• Copayment: is a flat-rate that has been agreed upon by the insurance company and healthcare provider for medical services. You typically pay the copay out of pocket to your doctor or provider.
• Coinsurance: The percentage you pay for medical services after you’ve met your deductible. Generally, coinsurance for Original Medicare is 20% of the approved costs.

Here’s how these terms apply to Medicare and chemotherapy:

What are Part A chemotherapy costs?

Part A is known as hospital coverage and helps pay for services received during inpatient care. You’ll have $0 coinsurance for the first 60 days you’re in the hospital, but only after you’ve met your Part A deductible. In 2022, it’s $1,556.

If you need hospitalization and chemotherapy for longer, you’ll pay daily coinsurance:

• Days 61-90: $389 per day
• Days 91 and on: $778 per day (up to 60 lifetime reserve days; after these 60 days, you’ll pay all costs)

What are Part B chemotherapy costs?

Many Medicare beneficiaries can receive their chemotherapy without requiring a stay in the hospital. Your coverage for these services, known as “outpatient,” comes from Part B. As with Part A, you’ll need first to pay your deductible. The 2022 Part B deductible is $233. Medicare will pay 80% of your approved costs once you meet the deductible; you’ll pay the remaining 20% coinsurance.

Part B also has its monthly payment, known as Part B premium. This starts at $170.10 per month. The Part B premium is income-based. The highest earners may pay as much as $578.30 per month for their part B policy in 2022.

What are Part D chemotherapy costs?

Chemotherapy can also be an effective solution when taken in other forms like pills and creams. If your doctor prescribes you chemotherapy to take at home, Medicare Part D will come into play. Part D is prescription drug coverage from private insurers. Because of this, each Part D plan can have different pricing. Most plans require you to pay a premium each month, as well as out-of-pocket copays to your pharmacist.

To help you figure out how much you may have to pay for your chemotherapy with Part D, take a look at your plan’s drug tiers. Health insurance companies classify the types and costs of prescription drugs with this system. The system determines how much of the price they will pick up and how much you’ll end up paying. Your prescription drug tier will have a dramatic effect on how much you’ll end up paying for your chemotherapy.

Original Medicare does not have out-of-pocket maximums. If you’re enrolled in Original Medicare and have met your deductible, you’ll continue to pay out-of-pocket Part B coinsurance any time you need outpatient chemotherapy. As shown above, in the case of Part A, you’ll pay more the longer you need hospitalization for chemotherapy. Fortunately, there are options to help cover your costs:

Medicare beneficiaries can purchase Medicare Supplement Insurance (Medigap). Offered by private insurance companies, Medigap plans can be purchased to help “close the gaps” in healthcare costs that exist with Original Medicare. Medigap can help pay for deductibles, coinsurance and copays . For Medicare beneficiaries that need regular, high-priced chemotherapy treatments, paying additional Medigap premiums can be a more cost-effective option than continuously paying coinsurance.

Another option for Medicare beneficiaries who need chemotherapy is to enroll in Medicare Advantage plans. Also called Part C, Medicare Advantage replaces Original Medicare (Part A & B), but covers the same benefits or coverage as Original Medicare. Medicare Advantage plans also include additional benefits, like out-of-pocket maximums (OOPM); once you’ve reached your OOPM, Part C will pay the rest of your costs for the rest of the year.

One of the biggest obstacles faced by Medicare beneficiaries with cancer can be the high cost of care, even for standard treatments like chemotherapy. Unfortunately, it’s a problem that doesn’t seem to be going anywhere — the American Cancer Society’s Cancer Action Network projects treatment costs will have increased by more than a third between 2015 and 2034.

One solution for fighting these rising costs is Medigap. With different levels of coverage, Medigap plans help cover out-of-pocket expenses like premiums, deductibles and coinsurance. In other words, the right Medigap plan can cover all of your out-of-pocket costs for chemotherapy. Keep in mind that Medigap has its monthly premiums; you won’t get these extra benefits at no cost.

When can I purchase a Medigap plan?

You have a six-month window to enroll in Medicare Supplement Insurance after you turn 65 and enroll in Medicare Part B. It is known as Medigap Open Enrollment, and you can sign up for any Medigap plan offered in your state. If you enroll during this window, the carrier can’t deny coverage due to any pre-existing conditions. Medicare beneficiaries generally get their lowest rates during this period.

If you want to add Medigap later, your options may be limited; you’ll typically pay more and be subject to medical underwriting, where you answer questions related to your health. At this time, Medigap providers are able to deny coverage because of past or current health conditions.

Part D (prescription drug) policies typically cover an array of chemotherapy treatments. These can include intravenous (IV) chemotherapy (given through the veins) or chemo in pill form. But it also may cover the drugs you’ll need as part of your treatment, even if they don’t treat cancer itself. For example, most policies will cover:

• Medications to treat nausea caused by chemotherapy

• Pain medications as part of your cancer treatment

So, how much is chemotherapy medication? All chemotherapy drugs covered by your Medicare are in your drug plans Part D formulary and broken down into tiers. The formulary tier will have assigned costs that allow you to see how much you’ll pay out of pocket.

What is catastrophic coverage?

Catastrophic coverage is the final coverage phase of a Part D plan. You’ll reach your catastrophic coverage only after you’ve met your regular deductible and paid your way out of the Part D coverage gap. Here’s how it works:

• Part D deductible: All Part D plans can have a different deductible, but they do not exceed $480 in 2022. Once you’ve met this amount, Part D will begin to pay a portion of your medication costs.
• Part D Coverage Gap: also called the Part D “donut hole,” this is a period that opens after you and your plan have spent a predetermined amount on prescription drugs ($4,430 in 2022). During this time, you will pay 25% of the approved costs for your generic medications, and Medicare will pay 75%. For name-brand drugs, you’ll generally pay 25% of approved costs, but using the drug’s full price can get you out of the coverage gap.
• Catastrophic coverage: Once your out-of-pocket costs have reached the yearly limit ($7,050 in 2022), you’ll leave the coverage gap and enter the final coverage stage. Catastrophic coverage offers the same coverage as the other levels, but you’ll pay reduced out-of-pocket coinsurance and copays.