Bladder Cancer and Medicare: What’s Covered and What’s Not?

In the case of bladder cancer, medically necessary treatments and services for outpatients (not admitted to a hospital) are covered by Medicare Part B. Part B covers:

• visits with your doctor (including oncologists and other specialists)
• diagnostic testing (bloodwork, X-rays)
• many chemotherapy drugs administered through an IV at your doctor’s office or a clinic
• some chemotherapy drugs administered orally
• outpatient clinic radiation treatments
• durable medical equipment, such as feeder pumps and wheelchairs

It’s a good idea to confirm coverage before receiving treatment. Talk with your doctor to better understand your treatment plan and coverage. If your doctor’s recommended treatment isn’t covered by Medicare, ask whether you can try any covered alternatives.

Medicare Part A covers inpatient hospital stays, including cancer treatments and diagnostics you receive as an inpatient. Part A also offers:

• some coverage for care at home, such as skilled nursing and physical therapy
• limited coverage for care in a skilled nursing facility after 3 days in the hospital
• care in a hospice

While Medicare covers some medications, such as chemotherapy drugs administered at your doctor’s office, it may not pay for others. These include:

• some oral chemotherapy drugs
• pain relievers
• anti-nausea medications

Always confirm coverage and expected costs before receiving treatment. If Medicare doesn’t cover the treatment you need, talk with your doctor about payment plans or other options.

Does Medicare cover BCG treatments for bladder cancer?

Bacillus Calmette-Guerin (BCG) is the standard immunotherapy drug for bladder cancer. Immunotherapy uses your own immune system to attack cancer cells.

In this case, a catheter is used to insert BCG directly into your bladder. BCG is typically used for noninvasive and minimally invasive bladder cancers, and it may be covered by Medicare if it’s deemed medically necessary by your doctor.

Even if Medicare covers some of your treatment, you may be responsible for premiums, deductibles, copayments, and coinsurance.

For example, Medicare Part B has a monthly premium of $144.60 in 2020 for most people; however, your costs may be higher depending on your income.

In 2020, most people also have a Part B deductible of $198. After the deductible is met, you’ll pay 20 percent of Medicare-approved amounts.

Plus, Medicare parts A and B might not cover some of the medication recommended by your doctor. In this case, you might have to pay out of pocket for the prescription.

To help with out-of-pocket costs such as copayments, you may consider a Medigap (Medicare supplement) plan, Medicare Part C (Medicare Advantage) plan, or Medicare Part D (prescription drug) plan.

Medigap plans can help you cover costs for copays and deductibles. You can choose from among 10 different plans, depending on factors like your location and coverage needs.

Medicare Advantage plans may also offer additional coverage. These plans must offer at least as much coverage as Part A and Part B of original Medicare.

Be aware, though, that you can’t have both a Medigap plan and a Medicare Advantage plan at the same time.

Medicare Part D is an add-on that can help cover the costs of prescription medications not covered by original Medicare. These include:

• certain oral chemotherapy medications
• pain relievers
• anti-nausea medications

Medigap, Medicare Part C, and Medicare Part D plans are all sold by private companies vetted by Medicare.

Several factors affect the cost of treating bladder cancer, including:

• how aggressive it is
• the stage at which it was diagnosed
• the treatment prescribed by your doctor

The starting point for managing your medical expenses is making sure that your doctor accepts Medicare assignment. This means they’ll accept the Medicare-approved treatment price as full payment.

Next, talk with your doctor about treatment recommendations, including medications. Discuss whether they’re considered medically necessary and accepted as such by Medicare.

If you have purchased a Medigap, Medicare Part C, or Medicare Part D plan, you might want to speak with the providers of those plans to learn exactly what they cover in the treatment plan set up by your doctor.

Medicare does cover treatment and services for bladder cancer, but you may still have significant out-of-pocket costs. This depends on factors like recommended treatment or the stage of your cancer.

Work with your doctor to develop a treatment plan that maximizes Medicare coverage. If you have additional coverage, such as a Medicare Part D (prescription drug) plan or a Medigap (Medicare supplement) plan, many of your out-of-pocket costs will be covered.