Cancer is a much more common disease than we’d like to believe. According to the National Cancer Institute, 38.4% of the people in the United States will be diagnosed with some kind of cancer during their lifetime – that’s 125,068,800 people out of our current population.
Some of the most prevalent forms of cancers among seniors are breast cancer, colon cancer, and lung cancer. Because aging can bring a higher risk factor for certain cancers, it’s important you know how well Medicare covers cancer. Fortunately, Medicare covers cancer quite well.
Common Cancer Treatments and Services
First, let’s talk about treatments and services that most cancer patients receive. This will help you to understand how specific procedures are covered under Medicare. Below is a short list of treatments, services, procedures, etc. that cancer patients may receive.
- Chemotherapy
- DME (durable medical equipment)
- Hospice
- In-patient hospital stays
- Medications
- Oncologist visits
- Radiation
- Skilled Nursing Facility (SNF) care
- Surgery
It’s true that Medicare covers most treatments, procedures, and services needed for managing cancer, but you need to know more than that. You should learn how each service is covered and how much you’ll pay for it.
While it’s hard to know for sure how much you will pay down to the cent due to certain factors, you can at least get a ballpark estimate of what you can expect to spend.
Medicare Part A Coverage
In short, Medicare Part A covers your in-patient hospital stays. In addition, stays at an SNF and hospice care are also covered under Part A among a few other things.
This may not seem like much for an entire part of Medicare to cover; however, if you think about how expensive these services are, it’s easier to understand. Also, depending on how recently you have left the hospital, there are times that Part A could cover things like DME and home health care too.
Costs Under Part A
Like all other parts of Medicare, Part A has a deductible. However, you will soon learn the Medicare Part A deductible is unlike any other deductible in Medicare. Most deductibles are annual; however, Part A’s deductible is per benefit period.
What this means is that if you go to the hospital multiple times a year, you could experience multiple benefit periods, and that means you could pay the Part A deductible more than once a year. As of 2019, the Part A deductible is $1,364.
The $1,364 deductible pays for your first 60 days in the hospital. If you stay in the hospital for more than 60 days, you will owe a daily copay. The daily copay for Part A start at $341 and increases to $682 after day 90.
The deductible also covers your first 20 days in an SNF if your doctor sends you to one to finish out your recovery. If your SNF stay is longer than 20 days, you will pay a daily copay of $170.50.
All costs after 150 days in the hospital or 100 days in an SNF are your responsibility.
Medicare Part B Coverage
Medicare Part B covers your outpatient services, treatments, procedures, and then some. They even cover some things while you’re in the hospital. Things like chemotherapy, radiation, surgery, and oncologist visits are all examples of things that can be covered under Part B.
Costs Under Part B
Medicare Part B has a monthly premium that is based on your income. Most people pay $135.50 each month in 2019 for Part B. The annual deductible for Part B in 2019 is $185.
Once you have paid your deductible, Part B will cover 80% of the cost for Medicare-covered services and treatments, like the ones listed above. The other 20% of the cost is your responsibility. Sometimes you can incur Part B charges while you are in the hospital, such as when a physician performs an outpatient surgery or you are using a hospital facility to get a diagnostic imaging scan, which is covered under Part B.
Let’s look at an example. Joe goes to the hospital for a minimally invasive surgery. He stays in the hospital overnight for observation. He will pay his Part A deductible of $1,364, his Part B deductible of $185, and 20% of the cost for the surgery and any other Part B services provided to him while in the hospital.
Medicare Plans That Can Help
Just from that one surgery, Joe could be paying thousands of dollars out-of-pocket. However, if he had a Medicare plan, he could be better protected from having to empty out his wallet.
Medigap Plans
Medicare Supplement plans, also known as Medigap plans, help cover the patients from having to spend so much out-of-pocket. A Medigap plan could potentially eliminate all of the costs that Joe would normally have to cover himself.
A few Medigap plans that could help Joe immensely are Plan F, Plan G, and Plan N. Plan F would cover everything mentioned above, while Plan G would cover everything except the $185 Part B deductible.
Most people only get one opportunity to enroll in a Medigap plan with guaranteed approval. So, if you have been diagnosed with cancer before becoming eligible for Medicare, you should enroll in a Medigap plan during this one-time open enrollment window.
Medicare Advantage Plans
Because Medigap plans usually have a higher premium, some people elect a Medicare Advantage plan instead. As long as you have one or the other you will be able to have extra coverage.
Medicare Advantage plans provide extra coverage in a few ways such as providing additional benefits, offering lower copays, and including a maximum out-of-pocket. In 2019, the set maximum out-of-pocket spending limit is $6,700 for in-network services.
This means, even if you can’t afford a Medigap plan, you will at least be covered from spending more than $6,700 for in-network services in any given year.
It takes some research to decide whether a Medicare Advantage or Medigap plan is the right fit for you, so make sure you learn how each type of coverage works before you choose a plan.
Medicare Part D Coverage
Part D is the part of Medicare that is in charge of your drug coverage – well, most of it anyway. There are some cases in which Part B would cover your medications, but we will get into that in a little bit.
Costs Under Part D
Each Part D plan has a premium. Currently, the national average for Part D monthly premiums is $35. You also have an annual deductible included in your Part D drug plan. In 2019, the maximum deductible a plan can set is $415.
After you have met your deductible you will move into the second stage of your Part D plan called the initial coverage stage. During this stage, you will pay copays for drugs covered under your plan. The copay you pay for any given drug depends on the tier the plan has the drug classified as.
After you and the carrier together have spent $3,820, you will move into the coverage gap. During this stage, you will pay a specified percentage depending on what type of drug it is, brand-name or generic.
Once your out-of-pocket spending hits $5,100, you’ll move into the catastrophic coverage stage which is the stage you will remain in until January 1st. In the catastrophic coverage stage, you will pay no more than 5 percent of your drug costs.
Drugs Covered Under Part B
Medicare Part B covers medications that are administered to you in a medical office setting. For example, chemotherapy is administered to you, therefore, Part B covers it, not Part D.
Think of Part D as your drug coverage for prescriptions you pick up at the pharmacy yourself. However, even Part B covers some of those.
Better Safe Than Sorry
We hear all the time, unfortunately, of how someone didn’t get Medicare Part D when they were first eligible because they weren’t taking any medications at that time. Well later, come to find out, they have been diagnosed with cancer and now must wait until the fall election period to enroll in a Part D drug plan.
Since they waited, not only will they have a lifelong late penalty tacked onto their premium, they have to pay 100% out-of-pocket from their medications until they get enrolled in a plan.
The potential of being diagnosed with cancer is also a reason why you should enroll in a Medigap plan when you are first eligible. Like we mentioned earlier, if you wait until it’s too late, you will be denied coverage due to your diagnosis. It’s always better to be safe than sorry.
Danielle Roberts is the co-founder of Boomer Benefits, where her team helps Baby Boomers navigate their new Medicare benefits.
Each company has a different process for enrolling in its PAP. Some applications require extensive financial information, while others require basic information; Some require doctors to fill out a portion of the application, while others only need a signed prescription. Miller says for the Genentech enrollment process, he had to provide his financial information and that the application had two or three pages for his doctor to fill out. Rosenguard says the Celgene application process was extremely simple and that it took about two weeks for him to be accepted into the program.
PAP Basics
