Medicare and cancer
Medicare is a U.S. government health insurance program designed for individuals over 65, those with certain disabilities, and people with end-stage renal disease or amyotrophic lateral sclerosis. It offers essential health coverage that has evolved since its establishment in 1965, impacting the lives of millions. When it comes to cancer, Medicare provides significant coverage for prevention, diagnosis, and treatment. Key features include coverage for routine screenings such as mammograms, cervical cancer tests, and colorectal cancer screenings, which are crucial for early detection. Additionally, Medicare facilitates access to clinical trials, allowing beneficiaries to explore new treatments while ensuring coverage for participation. The Medicare Modernization Act of 2006 further expanded options by introducing Part D, which covers prescription medications, including those necessary for cancer care. Despite these provisions, many cancer patients find that costs can still be high, prompting some to seek additional insurance or assistance programs. Overall, Medicare plays a critical role in helping older adults and those with disabilities access cancer care while navigating the complexities of coverage and costs.
On this Page
Subject Terms
Medicare and cancer
DEFINITION: Medicare is a United States government health insurance program. Individuals who qualify include those who have received Social Security disability income (SSDI) for two years, those with end-stage renal disease (ESRD) or amyotrophic lateral disease (ALS), and those over sixty-five.
History: The Medicare program has affected the lives of millions of Americans since President Lyndon B. Johnson signed the Medicare Bill of 1965 into law. The roots of this universal healthcare coverage for older adults and individuals with disabilities dates back to 1935 when the federal government introduced the first government health insurance bill. In 1945, President Harry S. Truman became the first president to endorse government health insurance for older adults. He became the first person to enroll twenty-one years later, receiving the first issued Medicare card.
In 1972, benefits for patients with disabilities and those with ESDR were added. The Supplemental Security Income (SSI) program came next, and hospice care benefits were added temporarily in 1982 and confirmed permanent in 1986. With the threat of budgetary problems, the diagnosis-related group (DRG) prospective payment system began in 1983. Until then, Medicare reimbursed for most covered medical charges at a “reasonable cost.” Several other changes evolved, including provisions for Medicare health maintenance organizations (HMOs) and the voluntary Part D outpatient prescription drug program, available to beneficiaries in 2006.
The Social Security Administration funds Medicare. To receive benefits, participants may have paid into the plan through their employers, qualify through their spouse or based on their medical condition, or pay a monthly fee to receive Part A.
Medicare basics: The Medicare program is divided into several parts. Part A is hospital insurance and covers inpatient stays with some follow-up costs after hospitalization. Also covered is care in a skilled nursing facility and hospice care. Part B is medical insurance and pays for physicians, nurse practitioners, and outpatient services. Part C offers several options, and Part D covers outpatient prescription drugs. Anyone who has worked and paid into the Social Security plan has the Part A benefit, but Parts B and D are optional and provided for a monthly fee. Medicare patients must meet annual deductibles for some benefits before receiving full plan coverage.
Medicare is less comprehensive than many private insurance plans. Many older adults opt to pay for secondary insurance coverage to pay the difference or gap in Medicare coverage for the provision of needed services. The high costs of many therapies and drugs have left many older adults and persons with disabilities without adequate insurance coverage or access to new modalities of treatment.
Coverage for cancer prevention and screening: In 2005, the Centers for Medicare and Medicaid Services (CMS) launched two national decisions for improving the care of cancer patients. Insurance coverage was expanded to include diagnostic tests and chemotherapy treatments for Medicare beneficiaries. One part of the preventive program is coverage for a “Welcome to Medicare” physical examination. This one-time benefit is designed to reduce the risk of serious health problems in the future.
Other services are covered as preventive health. For example, research shows that breast cancer risk increases with age. Annual mammograms are covered for women over forty on Medicare. Any Medicare recipient between thirty-five and thirty-nine receives one baseline mammogram. For patients requiring more than one mammogram yearly, the participant pays 20 percent of the Medicare-approved amount, and the Part B deductible applies.
Cervical cancer screening is provided through a Pap smear and pelvic examination (with breast examination) every twenty-four months. If the participant has an established high risk for cervical or vaginal cancer, arrangements can be made for these tests each year. The Pap test, test specimen collection, and pelvic exam are covered. For women between thirty and sixty-five, one human papillomavirus (HPV) test is covered every five years.
Discovery of precancerous polyps (growths in the colon) and removal can decrease the incidence and mortality rate of colon cancer. Medicare participants forty-five or older and at average risk for colorectal cancer are allowed fecal occult blood tests every year, flexible sigmoidoscopy once every four years, colonoscopy once every ten years (but not within four years of a sigmoidoscopy), and barium enema once every four years (instead of a colonoscopy or sigmoidoscopy). If the age forty-five or older Medicare recipient is at high risk for cancer, a colonoscopy is provided every two years, a flexible sigmoidoscopy every ten years, and a barium enema once every two years.
Medicare covers prostate cancer tests for men over the age of fifty. Coverage includes a digital exam and prostate-specific antigen (PSA) test yearly or more often if needed for diagnostic purposes. The digital exam requires a 20 percent copay with no coinsurance or Part B deductible for the PSA.
Medicare also covers lung cancer screenings for individuals fifty to seventy-seven who smoke, quit less than fifteen years ago, or smoked an average of one pack each day for twenty years at any time in their life.
Coverage in clinical trials: Medicare offers members more choices in participating in clinical trials for the diagnosis and treatment of cancer. In a clinical trial, research is conducted with participants to improve new ways of providing quality and effective cancer care. Participants can access promising new therapies as researchers find better, more effective ways to treat cancer. Many positives can come from participation, including being the first to benefit from a new treatment, gaining access to new treatments not available to the general public, having access to high-quality physician specialists, and helping future patients. The less attractive part of clinical trials is that new drugs may have unknown side effects, the new treatment may be less effective than the traditional one, and being in a clinical trial may require more doctor visits.
Although clinical trials are not for everyone, Medicare recipients now have choices with assurance of insurance coverage. Clinical trials receive funding from the National Cancer Institute (NCI) or NCI-sponsored groups to be covered.
Medicare Modernization Act: The Medicare Modernization Act of 2006 provided prescription drug coverage for Medicare recipients as Medicare Part D coverage. Drugs listed on the approved formulary are covered in this voluntary plan. Essential drugs needed by cancer patients, such as oral chemotherapy, immunotherapy, and hormonal therapy, are covered. Other valuable medications on this plan are drugs for the side effects of cancer treatments, such as nausea and low blood counts.
The plan is administered by diverse companies with variation in coverage, deductibles, and out-of-pocket expenses. Medicare patients have options but need to research which plan is best for them. It is recommended that Medicare participants keep a complete updated list of their prescription drugs and ask if a less expensive brand is available that is as effective. Local Social Security Offices have information to help participants compare plans to meet specific needs.
Even with Medicare drug insurance, medications used by patients with cancer can be expensive. Sometimes, state pharmaceutical assistance programs provide additional assistance to complement Medicare coverage. Sometimes the cancer patient can qualify for a low-income subsidy through Social Security. The oncology social worker can assist the participant to identify ways to get help for drug coverage and other services.
Bibliography
Field, Marilyn J., et al., editors. Extending Medicare Coverage for Preventive and Other Services. National Academy Press, 2000.
Kronenfeld, Jennie Jacobs. Medicare. Greenwood, 2011.
Lankford, Kimberly. "Navigating Medicare." Kiplinger's Personal Finance, vol. 68, no. 1, 2014, pp. 51–55.
Muller, Charlotte, et al. Costs and Effectiveness of Cervical Screening in Elderly Women. Office of Technology Assessment, 1990.
"Medicare Coverage for Cancer Prevention and Early Detection." American Cancer Society, 30 Sept. 2023, www.cancer.org/cancer/financial-insurance-matters/understanding-health-insurance/government-funded-programs/medicare/medicare-coverage-for-cancer-prevention-and-early-detection.html. Accessed 20 June 2024.
"Medicare." American Cancer Society, www.cancer.org/cancer/financial-insurance-matters/understanding-health-insurance/government-funded-programs/medicare.html. Accessed 20 June 2024.
Wu, Vivian Y, and Yu-Chu Shen. "Long-Term Impact of Medicare Payment Reductions on Patient Outcomes." Health Services Research, vol. 49, no. 5, 2014, pp. 1596–615.