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Does Medicare Cover Cancer Treatment After Age 76?
By Chris Gasparini
Chris Gasparini has been a licensed insurance agent since 2005. He enjoys helping Medicare beneficiaries navigate their options to find the best solution for their unique needs. Chris feels as though ...his work truly helps people. Because he represents multiple insurance companies and plan types, Chris is able to help Medicare beneficiaries find the most cost-effective plan. Every day, he leaves work knowing he did what was right for each and every client he serves.Read more
Apr 26, 2021
Yes, Medicare does cover cancer treatment after age 76. Medicare’s coverage for cancer treatment does not depend on age in any way. Although Medicare beneficiaries in some age groups will receive more frequent coverage for cancer testing, the coverage for medically necessary health services do not vary at all with age, no matter which Medicare insurance plan you have.
Let’s take a look at what you can expect when it comes to Medicare coverage for cancer treatment, regardless of your age.
Does Medicare cover cancer treatment?
Medicare health insurance provides fairly comprehensive cancer treatment. This includes services like chemotherapy and cancer screening, as well as surgery and hospital stays. Medicare coverage will vary depending on the type of Medicare you have, especially when it comes to drug coverage. However, basic treatment is covered by both Original Medicare and Medicare Advantage. We’ll go through the full details below.
Medicare coverage for cancer screenings and tests
There are a variety of types of cancer screenings that your healthcare provider may suggest as part of preventive coverage. This includes diagnostic screenings like mammograms to detect breast cancer, as well as other forms of testing, such as barium enemas for colorectal cancer.
This type of testing is covered by Medicare Part B unless it is conducted while you are a hospital inpatient. Then, Medicare Part A applies.
One of the only age-related restrictions to Medicare's cancer coverage falls under testing and screening. Individuals 50 or older who are at risk of colorectal cancer may be able to undergo testing more often than the rest of the population. This and other conditions mimic age and risk-related screening frequency allowances by Medicare for other conditions, such as diabetes.
Medicare coverage for cancer treatment
Medicare Part A hospital insurance is dedicated to covering inpatient care. Most often this means hospital care, but it can also refer to other types of inpatient services, such as skilled nursing facilities (SNF), hospice care, and home health care.
If your cancer care requires hospitalization, then it will be covered by Medicare Part A medical insurance, assuming you are admitted an inpatient. Part A will also cover research studies and testing that takes place during your hospitalization, as well as breast prostheses for breast cancer patients if your surgery took place in an inpatient context.
Basically, if you are an inpatient and receiving cancer treatment, you will be covered under Part A.
It is possible to receive hospital care as an outpatient or while under observation status. In these cases, your coverage is under Medicare Part B.
Medicare Part B covers outpatient healthcare services. This refers to all medically necessary care that takes place at a doctor's office as well as lab work, mental health care, durable medical equipment (DME), and more. Cancer-specific services include outpatient surgeries like breast prosthesis. Most routine cancer treatment that is not performed in a hospital will be covered by Part B.
Prescription drugs are not covered by Part B or Part A, but intravenous cancer drugs and chemotherapy drugs are. As a general rule, drugs that are administered in a healthcare setting, such as injections, are usually covered by Part B.
Durable medical equipment
Durable medical equipment refers to any equipment that is medically necessary to help treat a disease. This includes items like wheelchairs and canes as well as oxygen tanks and blood sugar monitors. If you need DME as part of your cancer treatment, the most important thing is to be mindful of where you purchase it from. If you don't use a Medicare-approved provider, you may have to pay the full cost of any DME you need.
Additionally, some DME providers will not accept Medicare coverage. Always ask the provider if they accept Medicare first. In addition, some types of DME require prior authorization before Medicare pays for them.
To find a Medicare-approved DME provider, click here.
Medicare Advantage and cancer treatment coverage
Medicare Advantage, also known as Medicare Part C, allows you to receive your Medicare coverage through a private insurance company. All Part C plans are required by law to provide at least the same level of coverage as Original Medicare (Parts A and B). Most Advantage plans offer additional benefits as well, such as prescription drug coverage and fitness programs. Plan details, including coverage and price, vary.
However, all plans offer the same level of cancer coverage that you find with Original Medicare plans. The main thing to remember is what extra coverage you may be able to receive as well as what provider network you are a part of so that you do not visit an out-of-network provider.
Medicare Advantage Prescription Drug Plans
Some Medicare Advantage plans come bundled with prescription drug coverage. This is very convenient for some, but others may be able to find a standalone drug plan that better suits their needs.
If you have one of these plans, make sure to look at the drug formulary to understand which prescription medications are covered. Each plan will be different, but many common cancer drugs are covered. Checking which tier the drug is on in the formulary can tell you what your out-of-pocket costs will be. The lower the tier, the lower your costs are.
Medicare Part D prescription drug coverage and cancer treatment
Although most Part C plans offer prescription drug coverage, Part D plans are still more common because two-thirds of beneficiaries choose to stick with Original Medicare.
Like Medicare Advantage, private insurance companies provide Part D plans instead of the federal government. If you have Original Medicare or a Medicare Advantage plan that doesn’t offer drug coverage, then you can buy a Part D plan.
Each Part D plan has its own formulary of covered drugs. However, many cancer drugs will be included on every plan, because it's one of the government requirements Part D providers must meet. Although this is a common type of coverage to receive, you should still make sure to check your plan’s details for specifics.
There may also be situations where a given cancer drug is covered by two different plans, but one plan has it on a more expensive tier. This means that both plans will cover the drug, but one will require a larger out-of-pocket payment from you.
How can Medicare Supplement plans help?
Medicare Supplement plans, also known as Medigap plans, help pay some of your out-of-pocket costs when you have Original Medicare. This means that, although they don’t directly cover medical care, they can help cover costs that you would normally have to pay yourself.
Private insurance companies offer Medigap plans and the costs will vary. However, plan coverage is standardized, and Medicare offers a comprehensive comparison of the types of plans that are offered.
These plans only cover costs associated with Original Medicare. This means that you cannot purchase one if you have Medicare Advantage. In addition, Medicare Supplement Insurance will not cover any co-payments or co-insurance fees related to your drug coverage.
These plans offer useful coverage, but it may be superfluous for some people. Much depends on your state of health. Medicare Advantage may be the better option if you're relatively healthy. Original Medicare plus a Medigap plan tends to work better for people who have multiple and/or serious health conditions. Ultimately it depends on your specific situation. For example, some cancer patients may frequently visit a provider that doesn’t accept Medicare assignment. In this case, a Medigap plan that covers excess charges would likely be useful but irrelevant for a patient who uses Medicare-approved providers.
Medigap plans use medical underwriting to decide whether to sell you a plan. However, they must sell you any plan they offer during your Medigap Open Enrollment Period, which lasts for 6 months and begins once you're both age 65 or older and enrolled in Original Medicare. This is one of the only times you have a guaranteed issue right with Medigap.
Out-of-pocket costs and Medicare coverage
In general, all of your cancer treatment will require the same out-of-pocket costs as other types of coverage under Medicare. This means that as you undergo covered cancer treatment, you will still have to cover your deductible, co-pay, and co-insurance costs.
These can vary slightly depending on your income level, whether you qualify for premium-free Part A, and the details of your Medicare Advantage plan (if applicable). Make sure to understand your out-of-pocket costs before treatment begins.
Final thoughts on cancer coverage after age 76
To reiterate: Medicare coverage for cancer treatment is no different after age 76. Medicare will cover your cancer treatment in the same way regardless of your age. As mentioned above, the one difference may be the frequency of testing before receiving a cancer diagnosis.
The key thing to remember as you begin cancer treatment under Medicare is that you know whether your provider accepts assignment and that you go through the proper channels for durable medical equipment. You should also make sure to understand your prescription drug plan’s tier list and drug formulary, so you aren’t hit with any unexpected fees.
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