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Medicare and Breast Cancer

Cancer is a disease prominent in aging adults. Older adults account for more than half of all cancer cases in the United States today, and the number only continues to rise. Aging adults are ten times more likely than young people to get cancer.The numbers are staggering, yet many seniors don’t receive recommended cancer screenings to decrease their risk.

The importance of Medicare coverage for cancer patients and survivors is paramount. Medicare – especially Medicare Supplement plans – provides quality health care coverage that is affordable and reliable for thousands of cancer patients today. In this post we’ll examine everything you need to know about Medicare and Breast Cancer coverage.

original-medicare-cardMedicare and Mammograms

Regular mammograms for women age 40 and older, or those that have a history of breast cancer in their family, are the best way to detect cancer early on. Not only are these diagnostic tests saving lives, they are also readily available in rural and urban areas alike.

Medicare covers screening and diagnostic tests such as mammograms when medically necessary for women who are 40 or older. Women who are age 35-39 may also receive a baseline mammogram.

Part B of Medicare covers many preventive screenings at no cost to you including annual breast cancer screenings once every 12 months. The mammogram must be provided by a provider who accepts Medicare assignment, meaning the provider accepts Original Medicare and/or Medicare Supplement plans.

On the other hand, diagnostic mammograms are not covered at no-cost to the consumer under Medicare Part B. Under Medicare Part B coverage, the patient is responsible for meeting their annual deductible ($166 in 2016) and paying 20% of the costs of the screening. Seniors enrolled in Medicare Supplement plans, however, may pay nothing for diagnostic mammograms, depending on the Medicare Supplement plan they’ve chosen.

Does the Women’s Health and Cancer Rights Act (WHCRA) apply to Medicare?

Passed in 1998, the Women’s Health and Cancer Rights Act (WHCRA) helps women by protecting and giving them the right to elect to have their breasts rebuilt (reconstructed) after a mastectomy, the process of removing all or part of the breast affected by cancer. This federal law applies to most insurance group plans and individual non-employer plans that cover mastectomies. However, not all group plans are required to cover mastectomies. Unfortunately, the WHCRA law does not apply to Medicare and Medicaid (the government-run health care for people who are indigent). However, Medicare does cover breast reconstruction (see Prostheses & reconstruction below for more information).

medicare-and-breast-cancerMedicare, Breast Prostheses, and Reconstruction Surgery

Women who undergo a mastectomy are covered for certain procedures by Medicare. Breast prostheses and reconstruction are covered with certain caveats. These procedures may help a woman maintain her sense of femininity and provide comfort after a devastating loss.

Under Original Medicare’s Part B coverage, a woman who undergoes a  mastectomy may receive external breast prostheses and post-surgical bras. The patient pays 20% of the Medicare-approved amount and the external breast prostheses after paying her Part B deductible.  

Part B covers breast reconstruction if the surgery was performed in an outpatient facility. Medicare Part A

Medicare Supplement plans fill in the gaps in Original Medicare’s coverage. As you can imagine, paying 20% of Part B surgery and the many costs associated with Part A coverage can be devastating for a family already going through a difficult situation.There are various levels of coverage through different Supplement plans, allowing patients to limit their financial exposure.

breast-cancer-pink-ribbonWhat Medicare Doesn’t Cover for Cancer Patients

Do you understand the costs that Medicare doesn’t cover? When it comes to cancer treatment and screening, Medicare covers quite a bit – but prescription drugs are a huge expense NOT covered by Original Medicare.

That’s where Medicare Part D comes in. While it is required that all Medicare beneficiaries have drug coverage, some forego coverage and face penalties. Some medications that are administered by a licensed professional are covered by Medicare Part B, such as chemotherapy and radiation, however a vast majority of drugs are covered by Medicare Part D. Without Part D coverage, cancer survivors risk paying high cost for their maintenance and post-surgical medications.

Medicare Part D plans will cover drugs that meet the following criteria:

  • Approved by the FDA
  • Sold and used in the U.S.
  • Not already covered under Medicare Part A or B (Part B covers some drugs that are administered by a physician)
  • Only available by prescription
  • Used for a medically accepted purpose

Medicare does not cover alternative medicine, which is a common treatment for cancer patients. These costs will need to come out of pocket. Holistic treatments, acupuncture, and chiropractic services (unless when medically necessary) are not covered.

Long-term care and nursing home care also isn’t covered, regardless of a cancer diagnosis or not. Short-term skilled nursing care, when followed by an inpatient hospital stay, is covered by Medicare Part A for a limited time if medically necessary. One caveat is that the patient must have been admitted for at least three days or their skilled nursing care will not be covered.

Seniors and baby boomers who are enrolled in Medicare Supplement plans will have better controll over costs – and in some cases will have no out of pocket costs – after receiving cancer care. While Original Medicare’s Part A and Part B do require coverage, there are often gaps in this coverage, leaving patients exposed to high financial risks.

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