Paying for Cancer Treatment
Most public and private health insurance plans cover the diagnosis and treatment of cancer. Patient costs and coverage for specific doctors, medical facilities or treatments may vary based on your health plan.
Even with health insurance, many people encounter significant out-of-pocket expenses for cancer treatment. You have a right to know what your costs will be. Your doctor’s office and medical facility should work with you and your insurance company to help you plan for the cost of your care.
Health insurers may deny coverage for certain tests, procedures or treatments considered to be experimental, “off-label” or different from the standard clinical treatment pathway. If your health plan denies any treatments or cancer-related services, your healthcare team can help you appeal the decision by demonstrating medical necessity.
Private insurance
Under the Patient Protection and Affordable Care Act (ACA), most group health plans, as well as policies sold in the Health Insurance Marketplace and small group and individual markets, cover essential health benefits, including cancer diagnosis and treatment. Copays, coinsurance and deductibles may apply. Your health insurance policy ultimately determines your costs throughout cancer treatment and recovery.
Note that short-term, temporary or catastrophic coverage health plans may not cover cancer treatment and can exclude coverage based on pre-existing health conditions, so it is best to avoid athese health policies.
Tumor Biomarker Testing
Precision medicine in cancer treatment is driven by tumor biomarker testing. Biomarker testing can determine if a tumor has certain features indicating that the cancer may respond better to a targeted therapy. A tumor test can also help establish the aggressiveness of the cancer and whether it’s likely to recur. Most private health insurers cover some biomarker testing for patients with certain cancers who meet established medical criteria. Insurers are more likely to cover specific, limited tests versus broad profiling. Coverage varies, so your oncologist should provide guidance. Many hospitals and oncology practices have nurse navigators, social workers or financial counselors who help determine insurance coverage and identify financial assistance when needed.
Lynch Syndrome
Testing for Lynch syndrome in people diagnosed with a Lynch syndrome-associated cancer often begins with tumor testing for:
- Microsatellite Instability (MSI)
- Immunohistochemistry (IHC)
Most private insurers cover this testing for patients who meet specific criteria. Surgeons who conduct Lynch-related biomarker testing are generally knowledgeable about established clinical and insurance coverage guidelines and can advocate on your behalf if needed.
Patients with tumor test results that suggest Lynch syndrome may be referred for genetic counseling and/or testing for an inherited genetic mutation. Insurance typically covers this, but copays, coinsurance and deductibles may apply.
Medicare
Medicare Part A (hospital insurance) generally covers the cancer treatment you receive as an inpatient. Medicare Part B covers many medically necessary cancer-related services and treatments you receive as an outpatient. You can be admitted to the hospital and still be considered an outpatient (observation status). Deductibles, coinsurance and copayments typically apply.
Your costs depend on several factors, including whether your healthcare provider accepts Medicare assignment, the type of facility, other insurance you may have and the location where you receive services. You have a right to know how much your out-of-pocket costs will be. Your doctor’s office and 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 your health plan to make sure your drugs are on the formulary (list of covered drugs) and 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 determine if the cancer is more susceptible to specific treatments, how aggressive it is and whether it is likely to recur.
- Medicare covers biomarker testing when the patient meets all of the following criteria:
- Has recurrent, relapsed, refractory, metastatic or advanced stage III or IV cancer
- Has not been previously tested using the same type of biomarker test (known as next- generation sequencing or NGS) for the same primary cancer diagnosis or repeat testing using the same NGS test for a new primary cancer diagnosis by the treating physician
Has decided to seek further cancer treatment (e.g., chemotherapy)
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.
Review your plan materials or call your health insurer 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. All state Medicaid programs are required to cover certain services, including inpatient and outpatient hospital services, as well as 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 healthcare providers or don’t have reliable transportation.
Medicaid also provides retroactive eligibility—covering the costs of medical care during the previous three months if you were eligible for Medicaid during that time. If you are newly diagnosed with cancer or 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.
Under existing law, state Medicaid programs generally must cover all of the drugs provided by manufacturers with 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 determine if the cancer is more susceptible to specific treatments, 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 typically 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 testing. 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 testing results that suggest Lynch syndrome may be referred for genetic testing for an inherited mutation.
Most state Medicaid programs cover genetic testing for individuals who have a blood relative with 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 may be eligible to receive both Medicare and Medicaid benefits, also known as “dual enrollment.” Medicaid may cover what Medicare does not.
Contact your state Medicaid office to learn more about your state’s cancer diagnosis and treatment benefits.
Supplemental Insurance
Supplemental insurance serves as a safety net. It helps pay for expenses not covered by your primary health insurance or costs you pay within your existing plan, such as deductibles, copays and other out-of-pocket expenses.
Supplemental insurance includes accident insurance, hospitalization insurance, critical illness insurance, disability insurance, hospital indemnity insurance and long-term care insurance.
Do you need supplemental health insurance plans if you already have health insurance? It depends on your risk factors, what you want to be insured for and how much insurance you want. If you know that you cannot afford the costs of your care or a loss of income if you are diagnosed with cancer, long-term care or critical illness insurance may be a good investment.
It is important to note that the Genetic Information Nondiscrimination Act (GINA) does not apply to supplemental health insurance policies. In many states, supplemental insurers may legally use information about your genetics, personal or family health history to determine policy eligibility or set premiums. The Privacy & Nondiscrimination section of our website provides details about your legal rights regarding health and genetic information.
See the Medical Leave & Disability section of our website for more information about disability laws and insurance options.