Medicare and Medicaid cover cancer treatment

In this section, you will find information about the coverage of cancer treatment, including tumor testing, under:

• Medicare
• Medicaid
• Fertility preservation
   

Medicare

Medicare Part A (hospital insurance) generally covers cancer treatment you receive as an inpatient. Medicare Part B covers many medically necessary cancer-related services and treatments provided on an outpatient basis. It is possible to be in the hospital and still be considered an outpatient (observation status). Deductibles, coinsurance and copayments typically apply.

Your costs depend on several factors, like whether your health care provider accepts Medicare assignment, the type of facility, other insurance you may have, and the location where you get your services. You have a right to know how much your out-of-pocket costs will be. Your doctor's office and treating medical facility should work with you to help you understand and plan for the cost of your care. 

Medicare Prescription Drug Plans (Part D) or Medicare Advantage Plans with Part D cover most prescription medications and some chemotherapy treatments and drugs. If Part B doesn’t cover a cancer drug, the Part D plan may cover it. It’s important to check with your plan to make sure your drugs are on the formulary (list of covered drugs) and to check the tier in which the drug is listed. This affects out-of-pocket costs.

Tumor Testing

Tumor biomarker testing looks for certain genomic abnormalities in cancer cells. A tumor test may be done to determine if the cancer is more susceptible to specific treatments or how aggressive the cancer is and whether it’s likely to recur. 

Medicare covers biomarker testing when the patient has:

1. Recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer; and
2. Either not been previously tested using the same NGS test for the same primary diagnosis of cancer, or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician; and,
3. Decided to seek further cancer treatment (e.g., chemotherapy)

The diagnostic laboratory test using NGS must have:

1. FDA approval or clearance as a companion in vitro diagnostic; and an
2. FDA-approved or -cleared indication for use in that patient’s cancer; and,
3. Results provided to the treating physician for management of the patient using a report template to specify treatment options

Biomarker tests that lack an FDA-approved companion therapy may be covered at the discretion of the regional Medicare Administrative Contractors (MACs). Patients still must meet the criteria defined in bullets A, B and C above.

Lynch syndrome

Testing for Lynch syndrome in people diagnosed with cancer begins with tumor testing. Medicare covers two different types of tumor tests to look for evidence of Lynch syndrome:

• Microsatellite Instability (MSI)
• Immunohistochemistry (IHC)

Patients with tumor test results that suggest Lynch syndrome may be referred for genetic testing for an inherited mutation.

In a family with a known Lynch syndrome mutation (MLH1, MSH2, MSH6, PMS2, or EPCAM), Medicare covers genetic testing only for individuals with:

• Signs and symptoms of Lynch-associated cancer, and
• A blood relative with a known Lynch syndrome mutation

Read your plan materials or call your plan for more information about your coverage and benefits. Visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get cost information.
 

Medicaid

Medicaid benefits for cancer treatment vary by state but care is generally similar to that of people with basic private health insurance. Every state’s Medicaid program is required to cover certain services including inpatient and outpatient hospital services, and laboratory and x-ray services. Medicaid covers non-emergency medical transportation in most states, which is helpful if you are too sick to drive yourself to your health care providers or if you don’t have reliable transportation.

Medicaid also provides retroactive eligibility—covering the costs of medical care that took place during the 3 months before finalizing the eligibility process for people who would have been eligible during those months. If you are newly diagnosed with cancer or if your income is being depleted to cover medical expenses, retroactive eligibility can be crucial in helping you get treatment instead of delaying or avoiding treatment altogether.

Under existing law, state Medicaid programs must cover all of the drugs for a manufacturer that has a Medicaid rebate agreement. This requirement ensures relatively broad access to medications and therapies for cancer patients with Medicaid. 

Tumor Testing

Tumor biomarker testing looks for certain genomic abnormalities in cancer cells. A tumor test may be done to determine if the cancer is more susceptible to specific treatments or how aggressive the cancer is and whether it’s likely to recur. Access to this type of testing for Medicaid recipients varies by state but it is generally more limited than what is available with private insurance or Medicare.

Lynch syndrome

Testing for Lynch syndrome in people diagnosed with cancer begins with tumor profiling. While coverage varies by state, Medicaid typically covers two different types of tumor tests to look for evidence of Lynch syndrome:

• Microsatellite Instability (MSI)
• Immunohistochemistry (IHC)

Patients with tumor test results that suggest Lynch syndrome may be referred for genetic testing for an inherited mutation.

The majority of state Medicaid programs cover genetic testing for individuals with a blood relative who carries a Lynch syndrome mutation (MLH1, MSH2, MSH6, PMS2, or EPCAM).

If you are age 65 or older with a disability and a very limited income, you could be eligible to receive both Medicare and Medicaid benefits. Medicaid may cover what Medicare does not.

Contact your state Medicaid office to learn more about the cancer diagnosis and treatment benefits in your state.
 

Fertility Preservation

Although infertility may be caused by cancer treatment or surgery, health insurers do not typically cover fertility preservation or related treatments. Several states have fertility preservation coverage laws that require private individual and group health plans to cover certain fertility services for women and men who will experience “iatrogenic infertility” (infertility caused directly or indirectly by surgery, chemotherapy, radiation or other medical treatment), but most do not apply to individuals with Medicare or Medicaid. 

If you do not have insurance coverage for fertility preservation, you should ask about discounts. Many clinics will provide significant cost reductions for patients who need fertility preservation and related procedures. In addition, some hospitals and adolescent & young adult (AYA) programs have charitable funds available to help offset sperm banking and other fertility preservation costs.

There are also grants and discounts available through established financial assistance programs.