Does Medicare Cover Radiation Therapy?

Radiation therapy is a common treatment for various types of cancer, using high-energy radiation to destroy cancer cells and shrink tumors. Patients often wonder how Medicare covers the costs associated with this medical procedure. Understanding how Medicare addresses these treatments is important for patients and their families.

Medicare Coverage for Radiation Therapy

Original Medicare, composed of Part A and Part B, covers radiation therapy when medically necessary and ordered by a Medicare-approved doctor. Most radiation therapy treatments are administered in an outpatient setting, falling primarily under Medicare Part B. Part B covers outpatient services, including physician services, facility fees for outpatient hospital or freestanding clinic treatments, and the technical components of administering radiation.

Medicare Part B helps cover the professional services of the radiation oncologist and other medical staff involved in planning and delivering the therapy. It also assists with costs for specialized equipment and the treatment facility. If radiation therapy is received while an individual is admitted as an inpatient to a hospital, these services typically fall under Medicare Part A, which covers inpatient hospital care.

Specific Radiation Services Covered

Medicare covers various radiation therapy services when medically necessary for cancer diagnosis and treatment. External beam radiation therapy, which delivers radiation from a machine outside the body, is a commonly covered method. Brachytherapy, an internal radiation therapy where a radiation source is placed inside the body, is also typically covered.

Advanced techniques like proton therapy, which uses proton beams to target tumors more precisely, are also covered. Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT), which deliver high doses of radiation to small, defined areas, are further examples of covered services. Coverage for these specialized treatments depends on them being prescribed by a qualified healthcare professional and meeting medical necessity criteria.

Understanding Your Out-of-Pocket Costs

Individuals enrolled in Original Medicare will incur out-of-pocket costs for radiation therapy. For outpatient services covered under Medicare Part B, beneficiaries pay the annual Part B deductible before Medicare pays its share. After the deductible, Medicare typically pays 80% of the approved amount, leaving the beneficiary responsible for the remaining 20% coinsurance. This 20% coinsurance applies to physician services, outpatient hospital services, and facility fees.

Some outpatient hospital services may also involve a copayment, which can vary based on the specific service and facility. These copayments are separate from the 20% coinsurance for physician and other professional services. The cumulative costs can add up during a prolonged course of radiation therapy.

How Other Medicare Options Impact Coverage

Medicare Advantage plans, also known as Medicare Part C, provide an alternative way to receive Medicare benefits and can impact radiation therapy coverage. These plans are offered by private insurance companies approved by Medicare and must cover at least the same services as Original Medicare Part A and Part B. However, Medicare Advantage plans often have different cost-sharing structures, including varying deductibles, copayments, and coinsurance for services like radiation therapy. These plans may also require beneficiaries to use in-network providers.

Medicare Supplement Insurance, or Medigap policies, offer another option for managing out-of-pocket costs. These policies work with Original Medicare, helping to pay for expenses that Original Medicare does not cover, such as Part A and Part B deductibles, copayments, and coinsurance. A Medigap policy can reduce the financial burden of the 20% Part B coinsurance for radiation therapy.