Does Medicare Cover Chemo and Radiation?

Medicare is a federal health insurance program for individuals aged 65 or older, and some younger people with specific disabilities. It helps manage healthcare costs, especially for complex treatments like chemotherapy and radiation. Understanding Medicare’s coverage for these treatments can be complex due to its various parts and distinct rules. This article clarifies how Medicare covers chemotherapy and radiation, outlining coverage methods and financial responsibilities.

Original Medicare Coverage for Chemotherapy and Radiation

Original Medicare (Part A and Part B) covers chemotherapy and radiation treatments. Coverage depends on where treatment is administered, affecting out-of-pocket costs.

Medicare Part A covers inpatient chemotherapy and radiation therapy when a hospital stay is required for complex procedures or complications. For 2025, the Part A inpatient hospital deductible is $1,676 per benefit period. A benefit period starts upon inpatient admission and ends after 60 consecutive days without inpatient care. For stays beyond 60 days, a daily coinsurance applies: $419 for days 61-90, and $838 for days 91-150 (lifetime reserve days).

Medicare Part B covers outpatient chemotherapy and radiation therapy received in a doctor’s office, outpatient hospital department, or freestanding cancer clinic. After meeting the annual Part B deductible ($257 in 2025), patients typically pay 20% of the Medicare-approved amount, with Medicare covering the remaining 80%.

Part B also covers physician services, medical supplies, and durable medical equipment (DME) for chemotherapy and radiation, such as infusion pumps, lab tests, and imaging. It covers some chemotherapy drugs administered intravenously or by injection in an outpatient setting. While oral chemotherapy drugs are typically Part D, Part B may cover some if they are the oral form of an injectable drug. Anti-nausea drugs administered within 48 hours of chemotherapy may also be covered.

Medicare Advantage Plan Coverage for Chemotherapy and Radiation

Medicare Advantage Plans (Part C) are private plans approved by Medicare. They must cover at least the same services as Original Medicare Part A and Part B, including chemotherapy and radiation. However, costs, rules, and network requirements can differ from Original Medicare.

Medicare Advantage plans offer the same basic benefits but may have different deductibles, copayments, and coinsurance for chemotherapy and radiation. For example, a Part C plan might have a copayment per outpatient chemotherapy visit instead of a 20% coinsurance. Many plans also include an out-of-pocket maximum, after which the plan covers 100% of additional costs for the year.

Medicare Advantage plan enrollees typically use in-network providers for the highest coverage. Out-of-network care can lead to higher costs or no coverage. Some plans require prior authorization for chemotherapy and radiation. Many plans also integrate prescription drug coverage (Part D), aiding in managing cancer treatment costs.

Role of Medicare Supplement Insurance (Medigap)

Medigap, or Medicare Supplement Insurance, is sold by private companies and works with Original Medicare. These policies help cover out-of-pocket costs like deductibles, coinsurance, and copayments that Original Medicare does not. For individuals undergoing chemotherapy and radiation, Medigap policies can significantly reduce financial burdens.

Medigap plans can cover the Medicare Part A deductible ($1,676 per benefit period in 2025) and Part A coinsurance for extended hospitalizations. For Part B services, including outpatient chemotherapy and radiation, Medigap policies often cover the 20% coinsurance after the annual Part B deductible is met, potentially minimizing or eliminating a patient’s out-of-pocket costs.

Medigap policies only work with Original Medicare and cannot be used with Medicare Advantage Plans. They generally do not cover prescription drugs, requiring a separate Medicare Part D plan for drug coverage.

Ensuring Coverage and Addressing Denials

Navigating Medicare coverage for chemotherapy and radiation requires attention to ensure services are covered and to address denials. A foundational requirement is that treatments must be medically necessary, meaning they are reasonable and necessary to diagnose or treat an illness or injury and meet accepted medical standards.

Before starting chemotherapy or radiation, especially with a Medicare Advantage plan, confirm any pre-authorization or prior approval requirements. Plans may deny coverage if these steps are not followed. Checking with your Medicare plan and healthcare provider beforehand can help prevent unexpected costs.

After receiving services, patients should review their Explanation of Benefits (EOB) or Medicare Summary Notice (MSN). An EOB from Medicare Advantage and Part D plans details billing, plan payments, and patient responsibility. For Original Medicare, an MSN summarizes services and payments over three months. These documents are not bills but detail claim processing.

If a chemotherapy or radiation claim is denied, patients have the right to appeal. The appeals process involves multiple levels, starting with an initial appeal to Medicare or the Medicare Advantage plan. Each denial notice includes appeal instructions. Providing supporting documentation, such as medical records and a doctor’s letter explaining medical necessity, can strengthen the appeal.