Does Medicare Cover Breast Cancer?
According to Breastcancer.org, about 1 in 8 U.S. women will develop breast cancer at some point in their lives. While breast cancer rates have been decreasing since 2000, it’s still incredibly common, and many women immediately get stressed about the potential medical costs.
While your mental, emotional, and physical health are of the utmost importance, cancer can be expensive. What will Medicare cover if you are diagnosed with breast cancer?
The Risks of Breast Cancer
Breast cancer is so common that it’s very likely you personally know someone who has been diagnosed. Whether it be your mother, a sister, a friend, or a distant relative, breast cancer is the second most commonly diagnosed cancer among American women (behind skin cancer).
As of 2019, about 30% of newly diagnosed cancers will be breast cancers. If you have a mother, sister, or daughter who has been diagnosed with breast cancer, your risk nearly doubles.
However, having no family history doesn’t mean you’re immune – only 15% of women who get breast cancer have a family member diagnosed with it. That’s right – about 85% of breast cancers occur in women with no family history of it.
The most common risk factors for breast cancer are just being a woman and getting older. The odds are stacked against us, ladies!
Types of Breast Cancer
There are many different types of breast cancer. The type is determined by the specific cells in the breast that have been affected.
The most common type of breast cancer is:
- Carcinomas: these are the most common, and they are tumors that start in the epithelial cells that line organics and tissues.
To get even more specific, most breast cancers are a type of carcinoma called adenocarcinoma, which starts in cells that make up glands. This starts in the milk ducts or milk-producing glands.
Rarer forms of breast cancer include:
- Sarcomas: this is less common, and is a tumor that occurs in the bones and soft tissues.
- Paget’s disease: this rare form of breast cancer accounts for less than 5% of all breast cancer cases in the U.S. and occurs when cancer cells collect in or around the nipple.
- Phyllodes: this is a very rare type of breast tumor accounting for less than 1% of all breast cancers. These are leaflike tumor cells that grow quickly but rarely spread outside the breast.
- Angiosarcomas: this rare type of cancer forms in the lining of the blood vessels and lymph vessels.
The type of breast cancer you have will affect your specific medical treatment, which will also have an impact on your total costs.
Breast cancer types information sourced from Breastcancer.org, American Cancer Society, and Mayo Clinic.
How Far Along Your Breast Cancer Is Will Greatly Impact Your Costs
What will have the greatest impact on overall medical costs is how far along the breast cancer has progressed.
A 2016 study completed by Helen Blumen, Kathryn Fitch, and Vincent Polkus examined the costs of care depending on which stage the breast cancer was when diagnosed.
This study found that overall, treatment costs were higher for patients whose cancer was more advanced when they were diagnosed. This is largely due to chemotherapy, which was responsible for the highest percentage of total costs for stage 4 patients.
In the second year after being diagnosed, chemo costs were the single largest contributor to treatment costs in every single stage of the disease.
However, for patients who were diagnosed early on (stage 0), their surgery costs were more than double those with stage 4 breast cancer, which reflects the curative nature of surgery for early-stage disease.
When looking at the average costs per patient allowed by the insurance company in this study, the expenses range from $60,000-$134,000 depending on how advanced the breast cancer was at diagnosis.
Those numbers can be striking, so it’s important to know: does Medicare cover breast cancer?
Does Medicare Cover Breast Cancer Treatment Such as Chemotherapy?
As we saw in the breast cancer costs study, the most significant cost for women diagnosed with breast cancer is chemotherapy treatment.
When looking at common breast cancer treatments like chemotherapy, Medicare does offer coverage.
Medicare Part B covers many chemotherapy drugs that are administered through your veins in an outpatient clinic or doctor’s office. Part B also covers some oral chemotherapy treatments.
Are Cancer Drugs Covered by Medicare?
For chemotherapy and other cancer-related drugs and supplies, your Medicare prescription drug plan may cover it.
Medicare.gov explains Part D covers most prescription medications and some chemotherapy treatments and drugs. If Part B doesn’t cover a cancer drug, your Part D prescription drug plan may cover it.
Please be sure to check with your plan to make sure your drugs are on the plan’s formulary (their list of covered drugs).
The following cancer drugs may be covered by your Medicare Part D drug plan:
- Prescription drugs for chemotherapy only available to be taken by mouth
- Anti-nausea drugs
- Other prescription drugs used in the course of your cancer treatment, like pain medication
Remember that Medicare Part B isn’t 100% coverage. You will still have a 20% coinsurance as well as a deductible. Be sure to consider a Medicare Supplement to pick up those costs.
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Does Medicare Cover a Double Mastectomy?
A mastectomy is a surgical operation to remove one or both breasts, partially or completely. This is done to treat breast cancer, but occasionally, it is done as a preventative measure for women with a very high risk.
Across the board, Medicare covers medically necessary surgical procedures. This means that Medicare will cover a double mastectomy as long as it is medically necessary.
If you’re considering a mastectomy as a preventative measure, you will need to talk with your doctor about what your costs may be. If your doctor does not feel the mastectomy is medically necessary, Medicare will not cover the procedure.
Breastcancer.org explains that Medicare helps cover breast reconstruction.
Medicare Part A, or your hospital insurance, helps cover surgically-implanted breast prostheses after a mastectomy if the surgery took place in an inpatient setting. If the surgery took place in an outpatient setting, Medicare Part B will help cover it.
Please remember: just because Medicare covers a mastectomy does not mean you will have no out-of-pocket costs!
It is highly advised to get a Medicare Supplement, which will either completely cover or greatly assist with the expensive 20% coinsurance as well as some deductibles and copays. (The level of coverage depends on which Medicare Supplement plan you choose.)
Does Medicare Cover Mammograms?
A mammogram is a low-energy X-ray of the breast to detect breast cancer.
Medicare is a huge advocate for screenings and preventive medicine, which is why Medicare Part B fully covers a screening mammogram once per year. Diagnostic mammograms can be done more frequently if it’s medically necessary.
Screening mammograms are free, and diagnostic mammograms come with a 20% coinsurance. A Medicare Supplement, if you choose to get one, would pick up that coinsurance.
Get more information: Mammograms and Medicare: What You Need to Know
Will Medicare Cover My Breast Cancer Costs?
Medicare offers coverage for medically necessary cancer expenses. However, it’s not full coverage. You will still have coinsurance, deductibles, and copays, which is why we recommend supplemental coverage called a Medicare Supplement.
These are very inexpensive to have, especially if you’re used to paying for traditional health insurance! (Think $120 per month instead of $800.)
If we didn’t go over a breast cancer service or test that you’re interested in, download the free “What’s covered” app from Medicare on your smartphone. There, you can type in any item, test, or service, and Medicare will tell you if it’s covered and what your costs will be.
For non-medical costs like loss of income, transportation to specialized facilities, lodging at those out-of-town hospitals, and more, we recommend securing a cancer insurance policy.
Cancer insurance is very inexpensive to have (as little as $30 per month), and they pay you a lump sum as soon as you are diagnosed with cancer.
Our team of dedicated, licensed agents can help you as little or as much as you need. Whether it’s answering a few questions about Medicare or creating a comprehensive Medicare Planner with you, we are your Senior Allies.
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