Health Insurance and Chemotherapy
Does insurance cover chemotherapy? It does, but that’s just part of the story. Here’s everything you need to know about how different health plans cover this cancer treatment, how much it costs with and without insurance, and how cancer insurance fits into the picture.
Beating cancer isn’t easy. It also isn’t cheap.
Why? Conquering cancer often requires a person to undergo a number of different treatments over a long period of time. That includes X-rays, MRIs, surgeries, radiation, chemotherapy, and other powerful drugs.
It isn’t unusual for someone’s cancer-care costs to total a hundred thousand dollars or more.
Chemo tends to be a big part of that whopping bill. How much it costs depends on a few factors, which you’ll learn about later. On average, though, a multi-week chemo treatment can come to $20,000 or even $30,000.
That brings up a few obvious questions. Does health insurance cover those charges? And if so, how fully does it cover them?
Both are answered below, as are the following:
- How do different types of health insurance cover chemotherapy?
- The cost of chemotherapy with and without insurance
- How cancer insurance covers chemotherapy
Does Insurance Cover Chemotherapy?
The short answer: yes, health insurance covers chemotherapy. In fact, insurance covers most cancer treatments that aren’t considered experimental.
But chemo isn’t a single drug or treatment, and health insurance doesn’t cover everything. Over 100 different drugs currently fall under the category of “chemotherapy.” Doctors choose among them depending on the type and stage of cancer. And sometimes they use more than one while treating a patient. Also, chemotherapy drugs come in a handful of forms:
- Pills that you swallow
- Creams or gels you rub into the skin
- Liquids healthcare professionals inject into the body or administer via an IV
- Wafers surgeons place near a tumor
All the above impact the price tag of a chemotherapy treatment cycle. For example, pills and other drugs you take by mouth – called oral chemo – can cost thousands of dollars a month, according to cancer.org.
That doesn’t mean that visiting a hospital outpatient department or physician’s office for shots or IVs is cheap. Those multi-month episodes often run into the tens of thousands of dollars as well--with the latter usually being quite a bit more affordable than the former.
The following influence the cost of chemotherapy, too:
- Where you buy your drugs (if you’re prescribed oral chemo)
- How often and how long you need treatment
- Your health plan’s deductible, copayments, and coinsurance charges
Ultimately, chemotherapy coverage depends on what kind of health insurance plan you have.
How Different Insurance Plans Cover Chemotherapy
Here’s how various kinds of health insurance plans cover chemotherapy.
Employer-sponsored or job-based plans
If you get insurance from an employer, you’re diagnosed with cancer, and your doctor prescribes chemo, your health plan should cover it.
That’s the good news. The not-so-good news: just because your job-based plan will cover it doesn’t mean it’ll cover it entirely. In other words, you may have to pay for part of your chemo on your own.
What you spend out of pocket for chemo with employer-sponsored health coverage depends on your policy’s deductibles, copays, and coinsurance costs. It also depends on how your policy treats prescription drugs, out-of-network care, and more.
In other words, even if you have a “good” health insurance plan, you may still be on the hook for thousands of dollars after your chemo treatments are over.
Health insurance from the marketplace – also referred to as Affordable Care Act or Obamacare plans – cover chemo.
That doesn’t mean your chemo treatments will be free. What you spend on them depends heavily on the deductibles, copays, and coinsurance costs on your plan.
Still, there are two big benefits to marketplace plans when it comes to chemotherapy. One is they all come with out-of-pocket maximums. In other words, there’s a limit to how much of your own money you’ll have to spend on your chemo. Another is they can’t limit how much they’ll spend in a year or in a lifetime. So, once you hit your out-of-pocket maximum, they’ll continue covering your care.
In 2019, the out of pocket maximum for an individual plan is $7,900 for in network care. Several plans have lower maximums, though.
For more information, check out this article: “Which Type of Obamacare Plan is Right for You?”
Does Medicare cover chemotherapy? Yes, it does.
Original Medicare comes in two parts: A and B. Which Medicare part covers chemo? It depends on the kind of chemo you need, and where you receive it (if you don’t give it to yourself at home).
For example, Medicare Part A covers chemo provided to enrollees who are hospital inpatients. Part B, on the other hand, covers chemo provided in hospital outpatient settings, physician’s offices, or freestanding clinics.
How much does chemo cost out of pocket if you have Medicare? if you’re a hospital inpatient, you’ll pay toward your Part A deductible plus any coinsurance you may owe. If you’re a hospital outpatient, you’ll be charged a Part B copay. And if you get your chemo in a doctor’s office or clinic, you’ll pay 20 percent of the Medicare-approved amount as well as toward the Part B deductible, if applicable.
On a related note, if you have Medicare Supplement insurance, sometimes called MedSup or Medigap, it may cover some or all these out-of-pocket costs.
Learn more about this kind of coverage in our article, “When Does it Make Sense to Get a Medicare Supplement Plan?”
Medicaid covers chemotherapy. But it’s hard to delve into specifics, because Medicaid varies so much from state to state.
To learn more about how your state’s program covers chemo and other cancer care, contact your local Medicaid agency.
How Much Does Chemotherapy Cost Without Insurance?
With so many different types of cancer and subsequent treatments, it’s hard to say how much they’ll cost you. There are several factors that impact how much chemotherapy costs:
- Type of cancer and treatment plan
- Your insurance plan
- Whether your care is in-network or out-of-network
- Where you get care
Estimating the cost of chemo becomes even more difficult when you consider that it’s usually given in conjunction with surgery, additional medication, and other treatments. AARP states that an average cancer treatment costs about $150,000. But that number accounts for more than just chemo.
One source says an initial chemo treatment costs about $7,000. That can jump to $30,000 for an eight-week treatment. But it doesn’t identify the type of chemo or where it’s provided. Another source suggests oral chemo drugs cost thousands of dollars a month.
At minimum, expect to pay thousands of dollars for chemotherapy without insurance. Also, the more treatments you need and the longer those treatments last, the more you’ll pay out of pocket for them.
How Much Does Chemotherapy Cost with Insurance?
This is even harder to pinpoint than the cost of chemotherapy without insurance. AARP says “insurance covers much of cancer’s medical costs. With a good policy, a patient is probably looking at a bill of more than $4,000 in deductibles and copays in a year before costs are fully covered.” But that number can vary quite a bit.
That’s because what you pay out of your own pocket for chemo depends on your health plan’s deductibles, copays, and coinsurance charges.
And the type of chemo and where you get your chemo can impact the price quite a bit. Out-of-pocket payments can be all over the map even if you have health coverage.
This is why it’s important to talk with your doctor and insurer after you’re diagnosed with cancer. You want to be clear about how your plan will cover various chemo treatments before you agree to them.
Does Cancer Insurance Cover Chemotherapy?
Cancer insurance is a kind of supplemental coverage. It pays some of the costs your primary health plan doesn’t.
Sometimes that means it covers your deductibles, copays, or coinsurance charges. At other times, that means it covers experimental treatments, care you receive from out-of-network providers, even daily living expenses.
In other words, it doesn’t necessarily cover chemo better than your main health insurance policy does. What it does is help you pay for those treatments by covering some or all the out-of-pocket costs tied to them.
Something to keep in mind: not all cancer insurance plans provide the same coverage. So, do your homework before settling on one.
Speaking of which, here are some of the best cancer insurance companies around:
To learn more about this type of add-on coverage, read our article about it: “11 Things to Consider Before You Buy Cancer Insurance.”
Does Health Insurance Limit Chemotherapy Coverage? Does Cancer Insurance Address Those Limits?
Some health plans limit the kinds of chemotherapy they’ll cover. They’ll cover some kinds, but not others. Or they’ll cover some more fully than they’ll cover others.
Cancer insurance can fill those gaps. “Can” is the key word here, though.
As you just learned, not all cancer insurance plans are the same. To get the most out of one, you have to know its coverage options and limits, as well as the coverage options and limits of your primary health plan, inside and out.
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