Does Medicare Cover Cancer Treatment?

Cancer treatment often involves substantial financial considerations. Understanding how health insurance, particularly Medicare, addresses these expenses is a primary concern. While Medicare provides significant coverage for cancer care, the extent of this coverage and associated out-of-pocket costs vary based on individual circumstances and chosen Medicare plans.

Medicare’s Core Coverage for Cancer Treatment

Original Medicare, comprising Part A and Part B, covers cancer-related services, with Part D addressing prescription medications. Medicare Part A, Hospital Insurance, covers inpatient services. This includes hospital stays for cancer-related surgeries, inpatient chemotherapy, or radiation therapy. Part A also extends to care in a skilled nursing facility following an inpatient hospital stay, hospice care, and certain home health services.

Medicare Part B, Medical Insurance, covers outpatient cancer care. It covers medically necessary doctor’s services, such as oncology visits, and outpatient hospital services. Chemotherapy and radiation therapy received in outpatient settings are covered under Part B, alongside durable medical equipment (DME) like wheelchairs or oxygen equipment. Part B also covers diagnostic tests, including MRIs, CT scans, laboratory tests, and preventive services like cancer screenings.

Medicare Part D provides prescription drug coverage for cancer treatment. This part covers oral chemotherapy drugs, anti-nausea medications, and other prescriptions used to manage symptoms or side effects. Part D plans have different phases of coverage, including a deductible, initial coverage phase, and catastrophic coverage, which can impact out-of-pocket costs for high-cost medications.

Enhancing Coverage and Managing Costs

Despite Medicare’s extensive coverage, individuals with Original Medicare (Parts A and B) incur out-of-pocket expenses such as deductibles, copayments, and coinsurance. After meeting the annual Part B deductible (e.g., $257 in 2025), individuals pay 20% of the Medicare-approved amount for most outpatient services, including many cancer treatments. Original Medicare does not have an annual out-of-pocket maximum.

To manage these costs, many individuals consider additional coverage options. Medicare Advantage Plans, also known as Part C, are offered by private companies approved by Medicare. They bundle Part A and B coverage, often including Part D and additional benefits. These plans have their own cost-sharing structures, including deductibles, copayments, and coinsurance, which can differ from Original Medicare. A notable feature of Medicare Advantage plans is an annual out-of-pocket maximum (e.g., up to $9,350 in-network for 2025), after which the plan pays 100% of covered services.

Another option for supplementing Original Medicare is a Medigap policy, or Medicare Supplement Insurance. These policies are sold by private companies and help cover some out-of-pocket costs of Original Medicare, such as deductibles, copayments, and coinsurance. Medigap policies work only with Original Medicare and cannot be used with Medicare Advantage plans. Some individuals may also have employer-sponsored or retiree health plans that coordinate with Medicare, potentially offering further cost-sharing assistance for cancer treatment.

Specialized Care and Support Services

Medicare covers various specialized care and support services for cancer treatment. Routine costs associated with participation in approved cancer clinical trials are covered by Medicare. This includes medically necessary services like hospitalizations, doctor’s visits, and lab tests, as well as care for complications arising from trial participation, provided these are services Medicare would cover. Medicare does not cover the experimental item or service itself, nor services provided solely for data collection not part of direct patient management.

Palliative care, aimed at providing relief from symptoms and stress of a serious illness like cancer to improve quality of life, is covered by Medicare. This care can be received alongside curative treatment. For those with a terminal illness and a life expectancy of six months or less, Medicare Part A covers hospice care, which focuses on comfort and support rather than curative treatment. Hospice care can be provided at home, in a hospice facility, or in a nursing home, though Medicare does not cover room and board in non-hospice facilities.

Medicare covers medically necessary skilled nursing care and therapy services provided at home. To qualify, a doctor must certify the patient needs skilled care and is homebound. This coverage includes physical therapy, occupational therapy, and services from a home health aide for personal care. Medicare also covers second opinions for surgery or major diagnostic procedures related to cancer. If the first two opinions differ, Medicare may cover a third opinion.

Navigating Coverage Decisions and Assistance Programs

Understanding how to address denials of coverage is important for managing cancer treatment costs. If Medicare or a Medicare Advantage plan denies coverage, individuals have the right to appeal the decision. The appeals process involves several levels, beginning with a redetermination by the plan or Medicare. If unfavorable, further appeals can be made, potentially leading to reconsideration by an independent review entity, and in some cases, an Administrative Law Judge hearing.

Beyond insurance coverage, various assistance programs help cancer patients with financial needs. Non-profit organizations and foundations offer financial aid for treatment costs, travel expenses, and lodging, especially for those who must travel for specialized care. Examples include programs providing free flights or lodging for patients traveling for treatment.

Pharmaceutical companies often have patient assistance programs (PAPs) that provide free or low-cost medications, including high-cost cancer drugs, to eligible individuals. These programs help manage prescription drug costs not fully covered by Medicare Part D. Many hospitals also offer financial assistance programs or have social workers who can guide patients to relevant resources, including state-specific programs or options like Medicaid for low-income individuals.