Medicare and Medicaid Coverage for Lung Cancer Patients
Fact checked by Maddy Simpson
Regardless of the cause of lung cancer, one thing remains true. Without the ability to detect these cancers early and without the means to treat them, more people will have poor outcomes. For many people, a lack of affordable quality health care is the biggest issue.
Thankfully, there are a number of health insurance options you can consider to cut costs and make a challenging situation more manageable. This article will address how Medicare and Medicaid can help, including who is eligible for these programs and what they cover.
More than a half-million Americans have been diagnosed with lung cancer at some point in their lives. The American Cancer Society estimates there will be more than 234,000 new diagnoses of lung cancer in 2024 and that more than 125,000 people will die from the disease. The five-year relative survival rate for lung cancer is 25%.
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The Cost of Lung Cancer
Lung cancer can come at a high cost. There are different phases of your medical treatment that should be taken into consideration.
Screening and diagnosis: You may need frequent visits with healthcare providers and tests like low-dose computed tomography (CT) scans and biopsies (a tissue sample is taken to analyze) to look for the disease. Screening may be pursued based on your risk factors or on symptoms you have.
Treatment: Once a diagnosis is made, decisions must be made on how to treat it. That may include chemotherapy (drugs that inhibit fast-growing cells), immunotherapy (drugs that teach the immune system to identify and destroy cancer cells), radiation treatment (high energy beams that destroy targeted areas of tissue), and even surgery.
Monitoring and follow-up: After the cancer is treated, you will continue to require regular follow-up visits and tests to make sure the cancer has not come back or is getting worse.
A 2019 study found the following costs for specific treatments:
Diagnosis and staging: Up to $14,000
Surgery: About $30,000
Chemotherapy: About $7000 per month
Radiation: More than $4000 per month
Newer lung cancer treatments, though effective, also can be very expensive. For example, immunotherapy can cost up to $15,000 per month.
While insurance (if you have it) can pay a large portion of these costs, out-of-pocket expenses can still be high. One 2017 study found that people with cancer spent 11%, on average, and up to 31%, of their household income on expenses related to their treatment.
Financial Assistance
Most people cannot afford the cost of lung cancer treatments without insurance or financial assistance. You may want to consider reaching out to prescription assistance programs (e.g., Pharmaceutical Research and Manufacturers of America’s Medicine Assistance Tool) or charitable resources (e.g., Patient Access Network Foundation's FundFinder) to keep costs in check.
If you have Medicare, you could significantly decrease your prescription drug costs with the Extra Help program.
Medicare vs. Medicaid
With the rising costs of lung cancer care, it is more important than ever to make sure you have health coverage. This is where Medicare and Medicaid fit in. Although they have similar names and both receive funding from the federal government, they are fundamentally different.
Medicare
Medicare was created in 1965 to provide health coverage for people over 65. It expanded its coverage to people with qualifying disabilities in 1973.
Part A: As part of Original Medicare, Part A is run by the federal government. It covers care you receive while you are hospitalized as an inpatient, care in a skilled nursing facility after an inpatient hospital stay, hospice care, and home health services.
Part B: Also part of Original Medicare, Part B covers care you receive in a hospital when you are under observation and care you receive outside of the hospital, including office visits, lab tests, imaging studies, preventive screening, therapy sessions, and some medications and vaccines.
Part C: Also known as Medicare Advantage, you can opt for Part C instead of Original Medicare. It covers everything that Original Medicare does but can add supplemental benefits and prescription drug coverage. This part of Medicare is run by private insurance companies.
Part D: Also run by private insurance companies, this part of Medicare covers prescription medications.
There are also Medicare Supplement plans known as Medigap plans that can help to pay down the costs that Original Medicare leaves on the table, like deductibles (an amount you pay before insurance covers the rest), copays (an amount you pay each time for a service), and coinsurance (a percentage you pay for a service, up to a yearly maximum).
Keep in mind these plans cannot be used in conjunction with a Medicare Advantage plan.
Medigap Open Enrollment
Medigap has a one-time Open Enrollment Period that starts the day you enroll in Part B and lasts six months. After that time, Medigap plans can increase their rates or deny you coverage based on pre-existing conditions, like lung cancer.
Some states offer additional enrollment periods that allow you to change to a different Medigap plan without facing rate hikes.
Medicaid
Medicaid was also created in 1965 but was intended to provide assistance for people with low incomes, rather than older adults or people with disabilities. That said, some people may qualify for both Medicare and Medicaid. This is known as being dual eligible.
While Medicaid receives some funding from the federal government, it is also partially funded and wholly run by the states. The federal government sets guidelines for what each state must cover. Beyond that, each state ultimately decides who and what is covered. Coverage may be provided by the state or by private insurance companies.
Does Medicare Cover Lung Cancer?
Medicare covers many services for lung cancer, but costs can still add up. A 2018 study in Cancer Medicine looked at the amount people on Medicare spent for lung cancer at different stages.
During the screening and diagnostic phase, the average spent was $861 per month. Chemotherapy and radiation costs averaged $4,242 to $8,287 per month over the first six months of care. The average cost of surgery, if pursued, was $30,096. This analysis, again, did not include the cost of more expensive immunotherapies.
Screening
Medicare Part B offers free lung cancer screening with low-dose CT scans to beneficiaries who meet qualifying criteria.
Specifically, they must be between 50 and 77, have no symptoms of lung cancer, have smoked within the past 15 years (or still be smoking), have a 20-pack-year smoking history (e.g., a pack per day for 20 years), and have their test ordered by a physician.
To be free, the test must be ordered by a doctor who accepts assignment (agrees to the Medicare fee schedule). In all other cases, screening and diagnostic tests will require you to pay a 15% coinsurance.
Screening vs. Diagnostic Tests
Screening tests are those that are performed when someone is at risk but does not have symptoms. Diagnostic tests, on the other hand, are those that are completed when someone is symptomatic.
Treatment
Part A covers chemotherapy, immunotherapy, and radiation treatments administered while you are hospitalized as an inpatient. It also covers surgeries that are on the inpatient only list and other surgeries depending on your situation.
In 2024, you will pay a $1,632 deductible for the first 60 days of your hospital stay as well as 20% for any physician fees. Hospital days 61 to 90 will cost you $408 per day and you will pay $816 for hospital days 91 and over. The latter are referred to as lifetime reserve days and Medicare only covers 60 of them in total.
Part B covers IV chemotherapy treatments administered by a healthcare provider, some oral chemotherapy agents, radiation treatments, and medically necessary surgeries that are not covered by Part A. You will pay 20% of the cost for each treatment.
Part D plans cover a wide range of chemotherapy treatments and can offer immunotherapy as well. You will pay deductibles, coinsurance, and/or copays for each drug, though the costs will vary based on your plan.
Other
Treatment is not the end of the lung cancer journey. You may require follow-up studies with blood tests, CT scans, magnetic resonance imaging (MRI), positron emission tomography (PET) scans, or X-rays to see if your cancer has come back or if it has spread to other areas of the body.
Unless you were hospitalized as an inpatient (Part A covers in that case), these studies would be covered by Part B.
Some cancer treatments can have long-term side effects. They may require monitoring and treatment all their own. Part B will cover services that are deemed medically necessary.
Part B will also cover the cost of visits with health providers ranging from physicians to physical therapists. Again, you would be responsible for 20% of the cost of each service.
Please know that this is not an all-inclusive list of tests and treatments for lung cancer and that other services may be covered.
Does Medicaid Cover Lung Cancer?
Medicaid covers your healthcare needs much like a private health plan. You will pay a copay or coinsurance for certain medications and services. Depending on the state you live in, you may be offered more or fewer benefits.
There may be differences in cost between Medicaid plans that are fee-for-service, i.e., run by the state, vs. those that are run by private insurance companies. The latter are referred to as managed Medicaid plans.
Screening
Interestingly, Medicaid is not required to follow the recommendations set forth by the U.S. Preventive Services Task Force. One of those recommendations is to screen for lung cancer in high risk individuals.
As of 2021, only 40 states with fee-for-service Medicaid cover low-dose CT scans for lung cancer screening. Unlike Medicare, the test may not be free. There could be cost-sharing involved.
Treatment
Medications: The federal government made prescription drug coverage optional for Medicaid but all states have opted to include it. As such, they are required to cover all medications approved by the Food and Drug Administration (FDA), including chemotherapy and immunotherapy treatments.
Unlike Medicare, Medicaid is allowed to negotiate prices with pharmaceutical companies and can accept rebates to keep costs down.
That said, Medicaid programs can limit which beneficiaries can get certain high-cost drugs. They do so by requiring prior authorizations, a pre-approval process to prove a treatment is necessary, or step-down therapy, a process where you try less expensive medications before trying more expensive ones.
Radiation therapy: Medicaid does cover radiation therapy in all states but the number of treatments covered and how much you pay for each treatment can vary.
Surgery: Surgery may be covered depending on your medical needs.
Other
Medicaid may cover diagnostic testing (e.g., biopsies, blood tests, CT scans, MRI scans, PET scans, etc.) and visits with healthcare providers. This is not an all-inclusive list.
Eligibility
To qualify for Medicare, you need to meet U.S. residency requirements and show medical need:
You must be a U.S. citizen or have been a legal resident for at least five consecutive years.
You must also be 65 years or older or have a qualifying disability.
Whereas eligibility for Medicare is the same nationwide, the criteria for Medicaid eligibility varies by state. You will need to meet state requirements, residency requirements, and income requirements. It will also depend on whether or not your state expanded Medicaid under the Affordable Care Act.
Requirements may include:
You are in a group that the federal government deems eligible for Medicaid. Alternatively, you live in a state that has Medicaid expansion. In that case, all adults are eligible.
You must also be a U.S. citizen, a legal resident, or a documented legal immigrant. Green card holders and some immigrants may need to wait five years before they qualify for Medicaid.
You also meet financial requirements based on a calculated modified adjusted gross income (MAGI). If your state offers a “medically needy program,” you may qualify for Medicaid even if your income is above the state’s MAGI level. The state will take your medical needs into consideration and will look at your medical expenses to decide if you qualify.
Enrolling in Medicare and Medicaid
To apply for Medicare, you will want to contact your local Social Security office, call 1-800-772-1213 (TTY 1-800-325-0778), or online.
To apply for Medicaid, contact your local Medicaid office, call 1-877-267-2323 (TTY 1-866-226-1819), or sign up at healthcare.gov.
Summary
Access to affordable health insurance is important as you manage your lung cancer. Costs will vary depending where you are in the course of your illness. Thankfully, Medicare and Medicaid both offer coverage from screening to treatment to routine follow-up.
A Word From Verywell
It is enough to deal with lung cancer, never mind the costs that can come with it. Find out if you are eligible for Medicare, Medicaid, or both. Your care will not be free but your costs will be significantly reduced.
Frequently Asked Questions
Can you get Medicaid if you have cancer?
Medicaid eligibility is based on your financial status, not on pre-existing conditions. As long as you meet your state’s residency and income requirements, you cannot be denied coverage.
That said, if you do not meet those income requirements but spend a lot on health care, some states offer a “medically needy” Medicaid program that can help.
What is the difference between Medicare and Medicaid?
Medicare and Medicaid receive funding from the federal government but they cover different groups of people. Medicare is intended for people over 65 and for people with qualifying disabilities.
Medicaid, on the other hand, is intended for people with lower incomes. It is possible to be dual eligible for both Medicare and Medicaid.
Does Medicare cover chemotherapy treatment?
Medicare covers chemotherapy but what is covered depends on what type of Medicare you have.
Medicare Part A covers chemotherapy you receive during inpatient hospitalization, while Medicare Part B covers certain types of chemotherapy when you are under observation in the hospital or when you are outside of the hospital. Other chemotherapy treatments may be covered by Medicare Part D.
Read the original article on Verywell Health.
