Breast cancer treatments like radiation and mastectomy not only help in managing the disease but also improve the quality of life and survival rates for patients.

However, understanding the financial implications of these treatments is essential. This article reviews how Medicare covers these breast cancer treatments, helping you or your loved ones make informed decisions and manage healthcare expenses effectively.

Does Medicare cover radiation for breast cancer?

Medicare offers comprehensive coverage for breast cancer treatment, including radiation therapy, one of the most commonly prescribed treatments for this disease. The coverage is covered by both parts of Original Medicare (Part A and B), depending on whether you receive treatment as an inpatient or an outpatient.

If you are treated as an inpatient, meaning you are admitted to a hospital, your radiation therapy is covered by Medicare Part A. The costs you will be responsible for include the Part A deductible, which is $1,632 in 2024. However, you will need to pay a daily coinsurance if your hospital stay extends beyond 60 days, starting from $408 per day from day 61 of your hospital stay.

On the other hand, if you receive radiation therapy as an outpatient or at a freestanding clinic, your treatment falls under Medicare Part B coverage. After you meet the Part B deductible of $240 in 2024, you will be responsible for 20% of the Medicare-approved amount for the therapy. Keep in mind that you will continue to pay $174.70 per month as your Part B monthly premium for 2024. 

For Medicare Advantage plan owners, the out-of-pocket costs for radiation treatment will vary depending on their specific plan as it is covered by private insurance companies who have different coverage plans on offer.

So, while Medicare does cover breast cancer treatment, it is not completely free. You will still need to pay certain out-of-pocket costs, which will depend on your specific treatment plan and the setting in which you receive care. Always consult with your healthcare provider and Medicare to understand these costs better.

Medicare Coverage	Coverage Scenario	Deductible (2024)	Coinsurance or Copayment
Medicare Part A	Inpatient radiation therapy	$1,632	Applies if hospital stay extends beyond 60 days
Medicare Part B	Outpatient radiation therapy or therapy at a freestanding clinic	$240	Responsible for 20% of the Medicare-approved amount after meeting deductible
Medicare Part C (Medicare Advantage)	Varies based on private insurance plan	Varies	Varies

Please note that these costs are estimates for 2024 and can vary based on your specific plan and treatment needs. Always check with your Medicare or Medicare Advantage provider for the most accurate and current costs.

Does Medicare cover mastectomy?

Medicare offers extensive coverage for mastectomy, a surgical procedure often recommended for breast cancer treatment or prevention. This coverage is provided through both Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), depending on the setting in which you undergo the surgery.

Medicare Part A covers inpatient hospital services. If your mastectomy procedure requires you to be formally admitted to the hospital with a doctor’s order, Part A coverage applies. In 2024, Part A entails a deductible of $1,632 for each benefit period, which covers the first 60 days of your inpatient care for free. It is crucial to remember that you are considered a hospital inpatient, and thus covered by Part A, only when you have a formal admission order from your doctor.

As per research published by the American College of Surgeons, 64% of mastectomies conducted between October 2017 and August 2019 were conducted in an outpatient setting. Medicare Part B covers a variety of services and items associated with outpatient surgery, including same-day outpatient procedures, doctor and other healthcare provider services, lab tests, X-rays, and medical supplies billed by the hospital. Also, if you require anesthesia services or certain drugs administered in these settings (like IV drugs), these are covered under Part B.

Furthermore, Medicare Part B coverage extends to necessary durable medical equipment and post-surgery supplies, such as mastectomy bras and breast prostheses. Just like other Part B-covered services, you will typically owe 20% of the Medicare-approved amount for these items. 

The out-of-pocket expenses of Mastectomy for Medicare Advantage Plan owners will vary depending on the type of plan they have. 

Does Medicare cover breast reconstruction after mastectomy?

Breast reconstruction surgery after a mastectomy can help restore the shape of the breast and improve the patient’s quality of life. Medicare covers breast prostheses for breast reconstruction if you had a mastectomy because of breast cancer. Additionally, the Centers for Medicare & Medicaid Services (CMS) indicate that reconstruction of the affected breast as well as the other unaffected breast following a medically necessary mastectomy are covered.

Breast reconstruction can either occur concurrently with the mastectomy or during a follow-up surgical procedure. Often, several operations might be needed to achieve the desired outcome.

The Women’s Health and Cancer Rights Act of 1998 ensures patients are covered if they decide to have breast reconstruction after a mastectomy. As per this Act, insurance must cover all phases of reconstruction on the breast where the mastectomy was performed. It also guarantees Medicare coverage for breast cancer reconstruction surgery on the opposite breast needed to achieve symmetry.

Furthermore, the Act ensures that treatments for physical complications resulting from the mastectomy, such as lymphedema, are covered. This comprehensive protection is vital to ensure patients receive necessary care following a mastectomy.

Just like radiation treatment and mastectomy, breast reconstruction is covered under Medicare Part A and Part B depending on whether the procedure is conducted in an in-patient or out-patient setting, respectively.

Conclusion

Navigating healthcare and understanding whether Medicare covers treatments such as radiation therapy, mastectomy, and breast reconstruction for breast cancer can be overwhelming. However, being informed about these services’ coverage is critical, as it can alleviate potential financial burdens, allowing you to concentrate more on your health and recovery. It’s crucial to have open dialogues with your healthcare provider and thoroughly review your Medicare plan, as this will allow you to understand and utilize the full range of benefits available for your treatment. Remember, your focus should be on your journey to healing, and knowing that your treatment is covered gives you the peace of mind needed to move forward confidently.

Article updated on January 18, 2024.