Medicare does provide coverage for cancer immunotherapy, which is great news for those seeking this treatment. However, it’s important to note that your out-of-pocket expenses will differ depending on the specifics of your Medicare plan, which part of Medicare covers your treatment, and whether you have any additional supplemental insurance.

Medicare coverage of immunotherapy for cancer patients?

In most cases, Medicare Part B will cover cancer immunotherapy. In this case, you will be required to pay a 20% coinsurance of the Medicare-approved amount for the treatment in an outpatient setting, but only after you’ve paid your annual Part B deductible, which is $240 in 2024.

On the other hand, if you have a Medicare Advantage plan (also known as Part C), your out-of-pocket expenses might include copayments and deductibles. The amounts for these can vary widely because Medicare Advantage plans are offered by private companies and have different structures and pricing.

Below, we expand upon the different parts of Medicare that cover cancer immunotherapy and what that means for the patient.

What Parts of Medicare cover cancer immunotherapy?

The Medicare part that covers immunotherapy depends on where you get the treatment.

• Medicare Part A: If you are admitted to the hospital and receive immunotherapy as an inpatient, Medicare Part A covers the treatment.
• Medicare Part B: When immunotherapy is administered in an outpatient setting, such as a doctor’s office or clinic, Medicare Part B usually covers it. Note that you might have to pay up to 20% of the cost as coinsurance. Having supplemental insurance can offset some or all of these expenses. Part B covers most immunotherapy drugs, excluding self-administered immune system modulators.
• Medicare Part C (Medicare Advantage): This is an alternative to Original Medicare and offers the same benefits, including immunotherapy coverage for both inpatient and outpatient settings. Many Medicare Advantage plans also encompass prescription drug coverage, which might help if you need an immunotherapy drug not covered under Part B.
• Medicare Part D: For immunotherapy drugs that are self-administered at home, such as immune system modulators, Medicare Part D provides coverage. However, the drug must meet certain criteria. It is advisable to check if the drug is listed in your plan’s formulary and its tier level, as lower-tier drugs typically cost less.
• Medigap (Medicare Supplement Insurance): For individuals with Original Medicare, Medigap can be a lifesaver. It covers 50-100% of out-of-pocket costs associated with Medicare Parts A and B, including costs for immunotherapy. However, Medigap does not cover self-administered medications and it has a monthly premium that can range from $100 to $300

What are the out-of-pocket costs of cancer immunotherapy for Medicare patients?

As per the Medicare costs set for 2024, for hospital stays covered by Medicare Part A, a $1,632 deductible is required per benefit period which covers the initial 60 days. While most hospitalizations don’t exceed this duration, costs can escalate if an extended stay is needed, with copays of $408 per day for days 61-90 and $816 per day for days 91-150. Beyond 150 days, the patient bears the full cost.

Medicare Part B, catering to outpatient therapy, requires a $240 deductible for 2024. Following this, beneficiaries pay 20% of the Medicare-approved charge for services and equipment, alongside a monthly premium of $174.70 (or more depending on their income.)

Medicare Advantage (Part C) and Part D offer different cost structures as they are privately managed. Medicare Advantage typically uses set copays instead of a coinsurance percentage, which can simplify expense estimation. These plans also cap annual out-of-pocket costs.

However, costs can be influenced by several factors, including whether your healthcare provider accepts assignment, the facility type, any additional insurance you possess, and the location of your service provider. Understanding these components is key to managing expenses while benefiting from crucial immunotherapy treatment.

Medicare Part	Deductible (2024)	Co-Payment/Co-Insurance	Notes
Part A	$1,632	$408/day (days 61-90), $816/day (days 91-150)	Applies per benefit period for a hospital stay
Part B	$240	20% of Medicare-approved charge	Also requires a standard monthly premium of $174.70
Part C (Advantage) & Part D	Varies	Set copays (Part C)	The out-of-pocket maximum limit in place

How to get Medicare-covered immunotherapy?

When seeking Medicare coverage for immunotherapy, the initial step is to confirm if your healthcare provider and the facility where you’ll receive treatment accept Medicare. This is crucial as it dictates the extent of coverage you can expect. While Medicare Parts A and B generally do not necessitate preauthorization, Medicare Advantage (Part C) and Part D might require preauthorization before you commence treatment. 

Being well-informed about your Medicare plan specifics and coordinating with your healthcare provider will enable a smoother process of obtaining essential immunotherapy under Medicare.

What is not included in Medicare immunotherapy coverage?

Medicare’s coverage for immunotherapy is primarily focused on the treatment itself, but there are several associated services and accommodations that it does not cover. These include:

• Room and board in assisted living facilities;
• Adult daycare services;
• Long-term nursing home care, which is considered custodial care;
• Medical food or nutritional supplements, with the exception of enteral nutrition equipment that might be necessary for patients with certain conditions.
• Non-skilled assistance with activities of daily living such as bathing, dressing, and eating.

It is important to be aware of these exclusions when relying on Medicare for cancer treatment through immunotherapy, as additional expenses may arise.

How long will Medicare pay for immunotherapy?

Medicare’s coverage for immunotherapy is built around the principle of medical necessity. This means that as long as immunotherapy is deemed necessary for your treatment by a medical professional, Medicare will continue to cover it. However, the specifics of your out-of-pocket costs will depend on whether your treatment is inpatient or outpatient.

For inpatient treatments, covered under Medicare Part A, the entirety of your immunotherapy cost for the first 60 days is covered. Beyond this period, you will be responsible for a copayment.

For outpatient treatments, which fall under Medicare Part B, the scenario is a bit different. Once you have met your deductible, you will be required to pay a 20% coinsurance for your immunotherapy treatment. This payment will continue for as long as your immunotherapy treatment lasts. Always check with your healthcare provider and Medicare to understand your precise responsibilities and coverage.

Conclusion

Understanding whether Medicare covers immunotherapy for cancer is essential for patients seeking this treatment. Being well-informed can alleviate financial stress and help focus on the healing process. Consult your healthcare provider and review your Medicare plan to ensure you are taking full advantage of the benefits available for your treatment.

Article updated on December 18, 2023.