What Is the Medicare-Approved Amount for Radiation Treatments?
Demystify Medicare's approved amount for radiation treatments to understand coverage and your financial obligations.
Medicare, the federal health insurance program, provides coverage for millions of Americans, primarily those aged 65 or older, and some younger people with disabilities. A central concept in this system is the “Medicare-approved amount,” which directly influences what Medicare pays and what patients owe for services received.
Defining the Medicare-Approved Amount
The Medicare-approved amount represents the maximum amount Medicare will pay for a covered healthcare service or item. This figure is determined by Medicare, not by the healthcare provider’s initial charge, and it acts as the foundation for both Medicare’s contribution and the patient’s out-of-pocket costs. Medicare establishes these amounts primarily through a fee schedule, which is a comprehensive list of services and their corresponding payment rates.
This fee schedule considers various factors, including the resources typically required to provide the service, the geographic location where the service is rendered, and the complexity of the procedure. Providers who “accept assignment” agree to accept the Medicare-approved amount as full payment for services, minus any applicable deductibles and coinsurance.
Medicare Coverage for Radiation Therapy
Radiation therapy is typically covered by Medicare when deemed medically necessary. Outpatient radiation therapy, which includes both the technical component for facility fees and equipment usage and the professional component for the physician’s services, generally falls under Medicare Part B. This part of Medicare covers medically necessary doctor’s services, outpatient care, durable medical equipment, and some preventive services.
If radiation therapy is provided during an inpatient hospital stay, it would typically be covered under Medicare Part A, which primarily covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services. The determination of whether care is inpatient or outpatient depends on the physician’s order and the hospital’s admission criteria, impacting which part of Medicare covers the services.
Patient Costs for Radiation Treatment
Patients receiving radiation treatments under Medicare Part B are responsible for specific out-of-pocket costs, even after Medicare coverage begins. Before Medicare starts paying its share, beneficiaries must first meet the annual Part B deductible. For 2025, this deductible is $240.
Once the deductible is satisfied, Medicare typically pays 80% of the Medicare-approved amount for most Part B services, including outpatient radiation therapy. The patient is then responsible for the remaining 20% coinsurance. For example, if the Medicare-approved amount for a service is $1,000, Medicare would pay $800, and the patient would owe $200, assuming the deductible has been met.
A significant consideration is “balance billing” when a provider does not accept assignment. Non-participating providers can charge up to 15% above the Medicare-approved amount for covered services. This additional charge, known as an “excess charge,” is the patient’s responsibility and does not count toward the Part B deductible or coinsurance.
Working with Providers and Bills
When seeking radiation treatment, it is important to confirm whether a provider accepts Medicare assignment before receiving services. Patients can directly ask the provider’s office or check with Medicare to determine the provider’s participation status. Knowing this upfront can help anticipate potential out-of-pocket costs and avoid unexpected “excess charges.”
After receiving services, beneficiaries will receive a Medicare Summary Notice (MSN) or an Explanation of Benefits (EOB) from their Medicare plan. These documents detail the services received, the amount Medicare paid, and the amount the patient may owe. Reviewing these statements carefully is important to ensure accuracy and understand the financial breakdown.
If a bill appears incorrect, or if there is a suspicion of improper balance billing, patients should first contact the provider’s billing department for clarification. If the issue remains unresolved, or if there are concerns about potential fraud or abuse, individuals can contact Medicare directly or seek assistance from their State Health Insurance Assistance Program (SHIP). SHIPs offer free counseling to Medicare beneficiaries.