Medicare covers medically necessary treatment of breast cancer. This includes a mastectomy or a double mastectomy, as well as reconstruction and prosthesis surgery.
Medicare Advantage, also known as Part C, is an alternative to original Medicare and provides all the coverage of parts A and B under one plan, including additional coverage.
Out-of-pocket expenses exist with both original Medicare and Medicare Advantage plans.
This article examines Medicare coverage for breast cancer and a mastectomy, along with the associated out-of-pocket costs. Then, it discusses breast cancer and the different types of mastectomies.
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.
If a person has cancer in both breasts, original Medicare and Medicare Advantage provide broad coverage for a double mastectomy.
The coverage also includes breast reconstruction and prosthesis implantation, in addition to non-surgical treatments, such as chemotherapy and radiation.
Some people who do not have breast cancer choose to have a prophylactic double mastectomy. This means they undergo the surgery to prevent the occurrence of the disease.
These individuals have a high risk of breast cancer due to a personal or family history of cancer. They also may have a genetic condition that increases their likelihood.
Medicare may or may not cover a prophylactic mastectomy and coverage is reviewed on an individual basis.
- inpatient hospital stays and inpatient cancer treatment
- home health care, such as physical therapy, following a hospital stay
- skilled nursing facility stay, after a 3-day related hospital stay
- surgical implantation of a breast prosthesis, if carried on an inpatient basis
Services that are not covered include:
- long-term nursing home care
- personal care services, such as assisting a person with bathing and dressing
- cosmetic surgery
Part A out-of-pocket costs include:
- $1,408 deductible for each benefit period
- $0 coinsurance for the first 60 days of a benefit period
- $352 coinsurance for days 61–90 of a benefit period
A benefit period starts the day a person enters a hospital and ends the day after they have been out of the hospital for 60 consecutive days.
Part B covers treatment and services that someone receives on an outpatient basis. This includes:
- many chemotherapy drugs administered in an outpatient clinic or doctor’s office
- some oral chemotherapy
- doctor visits
- diagnostic tests, such as X-rays
- radiation therapy administered in an outpatient setting
- medical equipment, such as walkers or wheelchairs
- outpatient surgeries
- in some instances, a second opinion for non-emergency surgery and third opinions if the first and second opinions differ
- external breast prostheses, such as a post-surgical bra
Part B out-of-pocket costs include:
- $144.60 monthly premium
- $198 annual deductible
- 20% coinsurance
Medicare Advantage plans provide the same coverage as parts A and B for mastectomy and breast cancer care.
Unlike original Medicare, they often include prescription drug coverage. A person with a plan may need to use in-network doctors and hospitals to get lower costs.
Costs of Medicare Advantage include deductibles, copayments, coinsurance, and monthly premiums, all of which differ among plans.
Medicare Advantage plans have an annual cap on out-of-pocket costs.
Part D plans provide prescription drug coverage that includes most chemotherapy medications. If a person’s Part B plan does not cover them, their Part D may.
An individual with original Medicare is eligible to buy a Part D plan. Each plan has a formulary or list of covered drugs, so a person may wish to check their plan to see if it includes their prescription drugs.
As with Medicare Advantage, the plans include deductibles, copayments, coinsurance, and monthly premiums, all of which vary.
Medigap, also known as Medicare supplement insurance, helps with uncovered costs associated with parts A and B.
The plans are available for people with original Medicare only.
Medigap plans have a monthly premium and depending on the plan, they provide 50–100% of certain uncovered parts A and B costs.
Breast cancer involves the abnormal growth of cells in the breast. According to the Centers for Disease Control and Prevention (CDC), it is the
The disease can start in any part of the breast, such as:
- lobules, which are the glands that produce milk
- ducts, which are the tubes that transport milk to the nipple
- connective tissue, which is the fatty and fibrous tissue that hold the parts of the breast together
Most breast cancers start growing in the lobules or ducts. The cancers can spread from the breast to other parts of the body through lymph vessels and blood vessels. If this happens, it is called metastatic breast cancer.
Treatment depends on the type of cancer and the extent of its spread. It can involve one or more of the following:
- surgery to cut out the cancer
- chemotherapy medication to shrink or kills cancer cells
- radiation therapy in which high-energy X-rays kill cancer
- hormonal therapy, to stop cancer cells from getting the hormones needed to grow
- biological therapy, which is an approach that helps the body’s immune system fight cancer cells
A mastectomy involves the surgical removal of the entire breast.
There are five types of this operation:
- total or simple mastectomy
- radical mastectomy
- modified radical mastectomy
- subcutaneous (nipple-sparing) mastectomy
- partial mastectomy
Total or simple mastectomy
A total mastectomy is the removal of the entire breast. It does not include the removal of lymph nodes in the underarm area or muscles underneath the breast.
A doctor may recommend this procedure for people with multiple cancers or large areas of cancer in their ducts, or people with a high risk of breast cancer who want to undergo prophylactic surgery.
A radical mastectomy is the most extensive. The entire breast is removed, all three levels of lymph nodes in the underarm area, and the chest wall muscles underneath the breast.
Doctors recommend this procedure for individuals whose breast cancer has spread to the chest muscles.
Modified radical mastectomy
A modified radical mastectomy involves the removal of both breasts and two of the three levels of lymph nodes in the underarm area. It does not include the removal of the chest muscles underneath the breast.
Doctors advise this procedure for people with invasive breast cancer.
Subcutaneous (nipple-sparing) mastectomy
As the name implies, a subcutaneous, or nipple-sparing, mastectomy involves the removal of an entire breast with the exception of the nipple.
A partial mastectomy involves removal of the part of the breast tissue that has cancerous cells, as well as some healthy tissue surrounding it.
The surgery is similar to a lumpectomy, but it removes more tissue.
Original Medicare and Medicare Advantage provide coverage for a double mastectomy, along with other breast cancer treatments, such as chemotherapy, radiation, and surgical implantation of a prosthesis.
Costs associated with both Medicare programs include deductibles, copayments, and coinsurance. If a person with original Medicare has a Medigap plan, it pays some of these expenses.
Someone thinking of having a double mastectomy may wish to check their Medicare plan for details on coverage and costs.