Medicare Coverage of Chemotherapy
What It Is
Chemotherapy treatments for cancer
Medicare Part A covers chemotherapy provided to an inpatient at a hospital or skilled nursing facility. Medicare Part B covers chemotherapy for an outpatient in any setting.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B plans.) To find out whether your plan provides extra coverage or requires different co-payments for chemotherapy, contact the plan directly.
If you have a Medicare Part D prescription drug plan: If you're enrolled in a Medicare Part D plan, it may cover outpatient prescription medications you take to manage symptoms of your disease or of the chemotherapy treatments. To find out whether your plan covers the outpatient drugs you're taking, and what your co-payments are for these drugs, contact the Part D plan itself.
What Medicare Pays
For a hospital or skilled-nursing-facility inpatient, the cost of chemotherapy is considered part of the overall covered hospital charges, which are paid by Medicare Part A under its schedule of deductible and coinsurance amounts.
For an outpatient, the amount of coverage Medicare Part B provides for chemotherapy depends on the setting in which the treatment is provided. For chemotherapy in a doctor's office, freestanding clinic, or independent treatment center, Medicare Part B pays 80 percent of the Medicare-approved amount for the treatment. If chemotherapy is provided by a hospital outpatient department, the patient is responsible for a fixed co-payment amount.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.