Medicare and Cancer

Serious healthcare concerns are scary enough without the threat of large bills. A question we get asked frequently is what is the best Medicare plan for cancer. Let’s discuss.

Parts of Medicare

Let’s do a quick breakdown of the Parts of Medicare to understand how they work. 

Original Medicare

Part A is your hospital insurance

Part B is your medical or outpatient insurance. Basically, anytime a doctor is involved.

Part A and Part B are Original Medicare. Basically, they are the default choice. However, there are other optional parts of Medicare. 

Medicare Advantage

First, there is Medicare Advantage aka Part C. Medicare Advantage plans are a replacement for Original Medicare. They must offer at least the same benefits as Original Medicare but will often offer additional benefits as well such as dental, vision, hearing, and prescription drugs. That’s right, prescriptions are not usually covered by Original Medicare.

You’ll also have lower deductibles and copays or coinsurance when compared with Original Medicare and you will have an out of pocket max. With a serious, long term illness, this can be especially important.

These plans are offered by private carriers and benefits can vary widely. You can view all available options on medicare.gov, but we highly recommend working with a broker. You can enroll when you first become eligible for Medicare, during a SEP if you qualify, or during the AEP which is every year from Oct. 15-Dec. 7. 

However, there are some very important drawback to Medicare Advantage that are especially critical when dealing with a serious or long-term illness.

Networks- you will likely need to operate within a (potentially restrictive) network.

Referrals- you will need a referral from your PCP for any specialists.

Preauthorization- your insurance will first need to preauthorize you for any specialty treatments or services.

Part D

Now let’s take about Part D which are your prescription drug plans. Many cancer treatments will actually by covered Part B, but you may still need Part D for other prescriptions to manage your condition. You can view your available options on Medicare.gov. Like Medicare Advantage, you can enroll when you first become eligible for Medicare, during a SEP if you qualify or during the AEP. 

You will pay an extra monthly premium to have access to lower cost prescriptions. The price for the drug is based on the tier. There are five tiers which get more expensive as you move from tier 1 to tier 5. You may have a deductible to meet, although many plans offer lower deductibles and no deductible for lower tier medications. 

Additionally, Medicare will track your spending as you move from deductible to initial coverage. If you continue to spend, you may reach the coverage gap or donut hole. During this time, your prescription drug costs will increase but if you continue to spend, you may reach the catastrophic coverage phase and your costs will drop drastically. Unfortunately, this will reset when your plan does. 

With difficult conditions, prescriptions can be more expensive. There are state pharmaceutical programs and pharmaceutical assistance programs that can offer incredible discounts on prescription drugs. Make sure to talk to your pharmacist about any potential options. And talk to your doctor to discuss generics as they will always be cheaper or even treatments that might fall under Part B as opposed to Part D.

Medigap

Finally and perhaps most importantly let’s discuss Medigap plans. For someone with a long term and serious illness (such as cancer) these are the gold standard for health insurance. You can enroll in a Medicare Supplement plan that can help to cover or possibly entirely cover all of the out of pocket costs of Original Medicare.

Remember with a Medigap plan, although it is offered by a private carrier, there are no networks. If your doctor or hospital accepts Original Medicare, they accept your supplement plan. So unlike Medicare Advantage, there are no networks, no referrals, and no preauthorization. It will allow you to see almost any cancer specialist without having to wait around on insurance.