If you want Medicare to cover any treatment, the first step is getting approval from a qualified healthcare provider.
Understanding cancer care can be complicated for a few reasons. Cancer care tends to involve a wide variety of treatment forms, from surgery to medications, and these are all covered in different ways by Medicare. Here we’ll focus on immunotherapy treatment, which can also vary according to several parameters. First, we’ll discuss what immunotherapy is and who it can be used for, and then get into the details of how it is covered by Medicare.
What is immunotherapy?
As the name implies, immunotherapy is a treatment option that involves the immune system. According to the American Cancer Society, immunotherapy seeks to use the cancer patient’s immune system to their advantage, by strengthening it to fight cancer cells in their body.
This can involve therapies that simply strengthen the immune system directly, or using lab-grown material that is similar in function to the human immune system to supplement it. Some immunotherapy medications, like Keytruda, involve injections, while others use oral drugs that help perform these functions.
There are various types of immunotherapy available. This includes checkpoint inhibitors, which act on t-cells, cancer treatment vaccines, therapeutic antibodies, and more. Each applies to different scenarios, and your doctor will be able to tell you what is most appropriate for you.
Who is immunotherapy for?
Immunotherapy can be used for a wide array of cancers, from lung cancer to lymphoma. The only thing that will determine whether or not some form of immunotherapy is right for you is whether or not your doctor thinks that it is appropriate. It is not limited to one type of cancer, but rather to specific scenarios in which it is deemed to be the most fruitful treatment option.
Medicare cancer coverage: An overview
Now, let’s take a look at how exactly Medicare covers cancer treatments. Generally speaking, Medicare will cover cancer treatment fairly comprehensively. Cancer drugs will usually be covered by Part D prescription drug plans, which aren’t part of Original Medicare. However, treatments like cancer surgery, tests, and outpatient treatment will be covered by Original Medicare.
Because immunotherapy takes many forms, it can be hard to say whether or not it will be covered without knowing the specifics. However, most immunotherapy will be covered by Original Medicare, while some immunotherapy treatments, if they’re in the form of self-administered drugs, may be covered by Medicare Part D instead.
Medicare Part A and cancer coverage
Medicare Part A covers inpatient care. Although this usually refers to hospitals, you can also be an inpatient at other locations, such as skilled nursing facilities or hospices. Part A will cover 80% of all medically necessary inpatient treatments, once you’ve met your deductible.
Because virtually all cancer care is medically necessary, you can expect to have any cancer care that you need to be covered by Part A. This includes most surgeries, which will be performed while you are an inpatient. Part A has specific limitations on how many days are covered per benefit period, so let’s take a look at these in more detail.
Part A coverage details
Part A provides coverage in what’s known as benefit periods. A benefit period begins the first day you are an inpatient and ends after you have been out of an inpatient facility for 60 days. If you enter a hospital, stay for 10 days, exit for 40, then enter for another 10, you’re still in the same benefit period.
Unlike most insurance plans, you will pay your deductible for each benefit period. In 2024, this comes to $1,632. Due to the nature of Part A benefit periods, you can end up paying more than one deductible per year.
Part A will cover the full cost of your hospital stay up to 60 days per benefit period. For days 61-90, you will pay $408 per day, and for days 91 and beyond, you will pay $816 for each lifetime reserve day in that benefit period.
Once you run out of lifetime reserve days (each person has 60, and they do not reset in a new benefit period), you will pay the full costs. However, once the benefit period resets, Medicare will again pay the full cost.
Medicare Part B and immunotherapy
Part B covers 80% of medically necessary outpatient care once you’ve met your deductible. Although Part B will usually cover medical services rendered in a place like a clinic or a doctor’s office, it can also cover emergency room care that doesn’t result in inpatient hospitalization. Part B will also be the source of coverage for durable medical equipment in most cases.
If your immunotherapy involves receiving an injection, IV, or another form of therapy that doesn’t involve hospitalization, then you can expect to be covered under Part B. Other parts of your cancer treatment like tests, diagnostics, and check-ups will also usually be covered by Part B.
Part B has a deductible of $240 per year. After it is paid, you will pay 20% of your treatment.
Medicare Part D for cancer care: Don’t overlook it!
Medicare Part D refers to prescription drug plans that are regulated by Medicare but offered by private insurance companies rather than the United States Government. These plans are only available to Medicare beneficiaries, but function quite differently from other parts of Medicare.
It’s important to note that Original Medicare does not cover prescription drugs. Although there are some exceptions, (for example, if a healthcare provider administers the drug, such as a shot), you should not expect drugs to be covered by Original Medicare. If you want prescription drug coverage, as most do, then a Part D plan, Part C plan that includes drug coverage, or other private plan are your only choices.
Part D plans will all have different formularies will also vary in price. Make sure that you examine the formulary to see if the drugs that you need are covered, and how much they will cost. Although Original Medicare covers many cancer treatments, cancer drugs that are self-administered will require an independent prescription drug plan for coverage.
Medicare Advantage and immunotherapy
Medicare Advantage plans, also known as Medicare Part C, offer a way to receive your benefits through a private insurance company. There are some regulations in place, so Part C plans cannot offer less coverage than Original Medicare. However, they can offer more coverage.
If you have a Part C plan, you should expect more or less the same coverage for cancer treatment. Some Part C plans have a prescription drug plan attached, and in this case, you should make sure that this drug plan provides the coverage that you need. If your Part C plan includes drug coverage, then you won’t be able to get another prescription drug plan or a Part D plan to supplement your coverage.
If you have a Part C plan and are getting ready to start immunotherapy, make sure that you check that your provider is in-network. Like most private plans, Part C plans have provider networks, which means that coverage can cost substantially more if you go to an out-of-network provider. This usually won’t matter for medical emergencies but can cause issues for routine treatment.
Can Medicare Supplement plans help?
Yes and no. Medicare Supplement plans, also known as Medigap, are plans that help to cover your out-of-pocket costs under Original Medicare. Rather than covering health care directly, Medigap plans will cover things like your Part A and Part B coinsurance and copayment fees.
Although this won’t actually give you more medical coverage, it can end up being a big help for those undergoing cancer treatments, which are often costly. There is a wide variety of Medigap plans to choose from, and they each have their own unique benefits. These plans are private, which means they will vary in cost. However, the coverage for Medigap plans is standardized.
Although they aren’t a good fit for everybody, everyone with Medicare should at least consider Medigap plans, as they can be a big help to some.
Medicare coverage and immunotherapy: What to remember
Immunotherapy falls under the general umbrella of cancer care, which will be covered by Medicare in the vast majority of cases. However, be conscious of whether your therapy is occurring while an inpatient or outpatient, and whether it involves any self-administered drugs. If you have a Part C plan, make sure you know that your provider is in-network. You should also stay on top of your Part D plan’s formulary, and see if enrollment in a Medigap plan will benefit you financially during your treatment.