Original Medicare, Part A covers the radiation therapy a person receives as an inpatient in a hospital. Part B covers the radiation therapy someone receives as an outpatient in a clinic.
Under original Medicare, coverage is available for both inpatient and outpatient radiation therapy with set out-of-pocket expenses.
Medicare Advantage is the alternative to original Medicare, so it provides the coverage of parts A and B for radiation therapy. However, out-of-pocket costs differ.
This article examines Medicare coverage of radiation therapy and other cancer treatment, as well as the out-of-pocket costs and how to get help with them.
Then, it discusses radiation therapy, when doctors prescribe it, and what side effects it may cause.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
All parts of Medicare help with the costs of medically necessary cancer treatment.
Original Medicare
Original Medicare consists of Part A, hospital insurance, and Part B, medical insurance. Part A covers cancer treatment someone gets in a hospital, including radiation therapy.
Also, Part A covers skilled nursing facility care for a limited time following a 3-day stay at a hospital.
Other possible cancer-related coverage of Part A includes blood, home health, and hospice care.
Part B covers radiation therapy in an outpatient clinic, along with the services below:
- many chemotherapy drugs given to a person through the vein
- some chemotherapy drugs that are taken by mouth
- outpatient surgeries
- doctor visits
- medical equipment, such as walkers and wheelchairs
- a feeding pump to deliver nutrition that someone uses in the home
- some screening and preventive services
- diagnostic tests, such as blood tests and X-rays
Medicare Advantage
Medicare Advantage, Part C, is the alternative to original Medicare. It provides the coverage of parts A and B. This includes radiation therapy and other cancer treatment.
Part D
Those with original Medicare are eligible to purchase a Part D plan, which is prescription drug coverage administered by private insurance companies.
If Part B does not cover an individual’s cancer medication that is taken by mouth, their Part D plan may cover it.
Before buying a Part D plan, a person may wish to check the policy formulary. Formularies are lists of medications that a plan covers, and they often differ between plan providers.
Other cancer-related drugs that Part D may cover include medications for nausea and pain.
Medigap
Medigap is Medicare supplement insurance, which is available for purchase to a person with original Medicare. The plans cover 50–100% of out-of-pocket costs associated with parts A and B, including those for cancer treatment.
Each part of Medicare has out-of-pocket costs that are detailed below.
Part A
Part A costs include:
- $1,408 deductible for each benefit period
- $0 coinsurance for the first 60 days of a benefit period
- $352 per day coinsurance for days 61 to 90 of a benefit period
A benefit period starts the day a person enters a hospital and ends the day after they have been home from the hospital for 60 consecutive days.
Part B
Part B costs include:
- $144.60 monthly premium
- $198 annual deductible
- 20% coinsurance
If someone receives radiation therapy in an outpatient hospital setting, they may also owe a copayment.
Parts C and D
In Part C, to get lower costs, a person may need to use in-network providers. All Medicare Advantage plans have an annual cap on expenses.
Parts C and D costs include deductibles, copays, coinsurance, and monthly premiums. These expenses vary among plans.
Medigap
The only Medigap cost is the monthly premium.
Out-of-pocket Medicare costs can be substantial, so much so, that a person with a low income may not be able to afford them.
The following programs can help pay the costs for people with limited means:
- Medicare savings programs help pay some deductibles, copayments, coinsurance, and premiums. Each of the four programs has eligibility requirements that depend on someone’s income and resources.
- Medicaid is a joint state and federal program that helps pay healthcare expenses for people who meet their income and resource requirements. It may also cover costs that Medicare does not cover, such as nursing home care.
- Extra Help provides lower rates for prescription drugs. Individuals who qualify for the program pay no more than $3.60 for generic drugs and $8.95 for brand name drugs.
A common treatment for cancer, radiation therapy is sometimes called radiotherapy or X-ray therapy. It delivers high-energy waves or particles to cancer cells.
A person’s cells usually grow and divide to form new cells. However, if someone has cancer, this process occurs faster.
Radiation causes small breaks inside cells’ DNA. This effect prevents cancer cells from growing and dividing, which leads to their damage or eradication.
Radiation can also affect the healthy cells that are near the targeted cancer cells, but most of them eventually recover.
Another form of radiation therapy involves taking radioactive substances by mouth or receiving them through a vein.
Although the substances travel throughout the body, they mostly collect in the area with cancer, so they have little effect on healthy cells.
According to the American Cancer Society,
Doctors advise radiation therapy for four purposes:
- to shrink early stage cancer
- to lower the risk that cancer will recur
- to reduce symptoms caused by advanced cancer
- to treat cancer that has recurred
Because radiation therapy can harm healthy cells, at least temporarily, it may cause side effects.
Regardless of the part of the body the therapy targets, it may produce tiredness and exhaustion.
Depending on the target, it may also cause other side effects, such as:
The harmed healthy cells normally recover within a few months after the end of radiation therapy. When this happens, the side effects disappear.
Some people may have side effects that do not get better with time. Others may have late effects that appear months or years after the end of their radiation therapy treatment.
Medicare covers radiation therapy and other cancer treatments. When a person with original Medicare undergoes the treatment during a hospital stay, the out-of-pocket costs include a $1,408 deductible. If their hospitalization extends past 60 days, they owe a coinsurance.
When someone with original Medicare undergoes radiation therapy in an outpatient clinic or doctor’s office, their out-of-pocket costs include a $198 deductible and a 20% coinsurance.
Out-of-pocket costs of Medicare Advantage plans are different. A person may wish to check their plan to get an idea of the expenses to expect.
People who cannot afford their Medicare costs may qualify for one of the programs that help those with limited income and resources.