By: Danielle Kunkle – Vice President of Boomer Benefits
Enrolling in Medicare is often nerve-wracking for anyone turning 65. It can be especially scary to transition into Medicare while undergoing treatment for a serious health condition like breast cancer. Patients worry that their pre-existing conditions may not be covered or that they’ll have to change their providers. They are also unfamiliar with Medicare’s network and how Medicare will cover their medical services.
The good news is that Medicare provides quite comprehensive coverage for both inpatient and outpatient cancer treatments. When combined with the right supplemental coverage, people often find that they will have little out-of-pocket spending for cancer services. Let’s look at Medicare’s benefits and coverage:
Hospital Coverage: Medicare Part A
Medicare Part A covers inpatient stays, blood transfusions, skilled nursing, hospice and some home health care services provided in the hospital. For the first 60 days of an inpatient hospital stay, you as the beneficiary will owe a deductible ($1317 in 2017). Most hospital stays are well under 60 days, so this may be your only Part A spending.
However, if your stay lasts longer than 60 days, you will begin to incur a daily copay. Fortunately, there are Medigap plans that cover the deductible and the daily copays. We’ll cover those shortly below.
Outpatient Medical Coverage: Medicare Part B
Medicare Part B is your outpatient medical coverage. This includes things like doctor visits, lab work, xrays, diagnostic imaging and durable medical equipment. It also covers surgeries (including reconstructive surgery), chemotherapy and radiation. For cancer patients, there is important coverage of second opinion consultations, participation in clinical trials, and coverage of injectable medications.
After a small annual deductible, Medicare Part B will cover 80% of these costs. You are responsible for the other 20%, but Medigap coverage is available to cover this as well.
Important preventive benefits are covered at 100% by Part B as well, including mammograms, well woman exams, and colonoscopies.
Drug Coverage: Medicare Part D
For over 40 years, there was no retail prescription drug coverage for people on Medicare. In 2006, however, Congress added a drug program to Medicare called Part D. Part D plans provide drug coverage to Medicare beneficiaries at reduced copays. Think of Part D as a pharmacy card that lets you pick up your own prescriptions at a retail pharmacy. This benefit ensures that you do not have to pay full price for your covered medications.
Most cancer patients will have some medications that fall under Part B, and some that fall under Part D. The general rule is that if your medication is injected in a doctor office or clinical setting, the medication will fall under Part B. Traditional chemotherapy administered via infusion is an example.
However, there are some oral chemotherapy medications that may fall under Part D. If you are picking up the prescription yourself at your local pharmacy, chances are that this will be covered by your Part D drug plan. Likewise, some anti-nausea medications will fall under Part B while others will fall under Part D. If your doctor provides the medication to you within 48 hours of a cancer treatment, Medicare Part B will likely cover it. If he gives you the prescription to fill yourself at any time, then the drug will likely be covered by Part D.
If you are unsure how a medication will be covered, ask your doctor or pharmacist about what costs to expect.
Supplemental Coverage: Covering the Gaps
Since Medicare leaves you to pay the Part A and Part B deductibles as well as 20% of all outpatient services, most people purchase supplemental insurance to cover the gaps. You will generally have two main Medicare supplement insurance options. It’s important to understand how your coverage affects your cost-sharing and your access to healthcare providers.
Traditional Medicare supplements pay after Medicare pays its share. Often called Medigap plans, these policies are standardized by the federal government. This makes it easier for you to compare plans between insurance companies. There are 10 standard Medigap policies lettered A, B, C, D, F, G, K, L, M, N and one high deductible option.
Each plan letter covers a specific set of benefits. If you only need basic coverage of the 20%, then a Medigap Plan A will suffice. If you want all deductibles and excess charges also covered so that you have almost nothing out of pocket, then Plan F or G are good options. Visit this chart to see what each Medigap plan covers and compare them side by side.
With Medigap plans, you can see any provider in the nation that accepts Medicare. There are over 800,000 providers in the network, and most cancer treatment centers and oncologists accept traditional Medicare. No referrals are necessary either. You can see your specialists at any time.
Another option available to Medicare beneficiaries to cover the gaps is Medicare Advantage, otherwise known as Part C. Advantage plans are private Medicare plans that pay instead of Medicare. Most plans will have a local HMO or PPO network, and you must treat with these providers to get the lowest out of pocket costs.
While often cheaper than Medigap plans, you will have more cost-sharing as you go along. For example, you will have copays for visiting the doctor and for labwork, surgeries, hospital stays, durable medical equipment and most other services. Some Medicare Advantage plans charge as much as 20% for chemotherapy, but each plan also has a cap, called the Out of Pocket Maximum. This cap protects you from spending beyond a certain dollar limit set by the plan.
Please note that Medicare Advantage networks are much smaller than traditional Medicare. Before enrolling, make sure that your oncologist and other important doctors are in the network for the plan you are interested in.
A Word about Doctors
Many cancer patients who are New to Medicare fear that transitioning to Medicare may mean they will have to change providers. This is generally not the case. Most physicians and hospitals in America accept traditional Medicare. This means that Medicare with any Medigap plan will provide you access to these doctors as well as excellent coverage for your various medical services related to cancer. If you find that your provider does not accept Medicare, you can search for other providers using Medicare’s online Find a Doctor tool.
Transitioning to Medicare while treating for cancer can cause anxiety because there is the fear of the unknown. However, many cancer patients find their Medicare coverage to be quite thorough when combined with the right supplemental coverage. When reviewing your options, think about which coverage will provide you the most peace of mind so that you can concentrate on getting well.
Danielle Kunkle is the co-founder of Boomer Benefits, an insurance agency specializing in Medicare-related insurance products. They help baby boomers New to Medicare learn about their benefits and coverage options across 47 states.