Paying for Cancer Care: Medicare Coverage and Cost Sharing

Adapted from Medicare Coverage of Cancer Treatment Services, Centers for Medicare & Medicaid Services. The selected guidance concerns Medicare coverage and payment, not a recommendation for medical treatment. Numbered page references below refer to the linked source publication.

Coverage can depend on medical necessity, the setting, provider participation, and your plan’s rules. Use the cited publication for the full conditions and check the plan year when comparing costs or enrollment choices.

What Medicare Covers

Medicare Part A (Hospital Insurance) covers:

• Inpatient hospital stays, including cancer treatments you get while you’re an inpatient in the hospital. You may be in a hospital and still be considered an outpatient (also called observation status). If you’re unsure if you’re an inpatient, ask the hospital staff.
• Skilled nursing facility care (following a related 3-day hospital stay).
• Home health care (like rehabilitation services for physical therapy, speech-language pathology therapy, occupational therapy, or skilled nursing care).
• Blood.
• Some costs of clinical research studies while you’re an inpatient in the hospital.
• Surgically-implanted breast prostheses after a mastectomy, if the surgery takes place in an inpatient setting.
• Hospice care.

Medicare Part B (Medical Insurance) covers:

• Many medically-necessary cancer-related outpatient services and treatments, but for some services, you must meet certain conditions. You may be in a hospital and still be considered an outpatient (observation status). Part B also covers some preventive services for people who are at risk for cancer.
• Doctors’ visits.
• Many chemotherapy drugs that are administered through your vein in an outpatient clinic or a doctor’s office.
• Some oral chemotherapy treatments.
• Radiation treatments in an outpatient clinic.
• Diagnostic tests (like X-rays and CT scans).
• Durable medical equipment (DME) (like wheelchairs and walkers).
• Specific dental services you’d get at a dentist’s office or other outpatient setting if they’re directly related to the success of covered cancer treatments (like dental care you might need to get before chemotherapy).
• Enteral nutrition equipment (feeding pump) as DME that your doctor prescribes for use in your home, and certain nutrients if you can’t absorb nutrition through your intestinal tract or you can’t take food by mouth.
• Outpatient surgeries.
• Breast prostheses (external breast prostheses, including a post-surgical bra) after a mastectomy. Part B covers surgically implanted breast prostheses after a mastectomy if the surgery takes place in an outpatient setting.
• In some cases, a second opinion for surgery that isn’t an emergency, and a third opinion if the first and second opinions are different.
• Mental health services, including services that you usually get outside a hospital (like in a clinic, doctor’s office, or therapist’s office) and services you get in a hospital’s outpatient department.
• Nutritional counseling if you have diabetes or kidney disease.
• Certain preventive and screening services.
• Some costs of clinical research studies while you’re an outpatient.

What you pay for services

Copayments, coinsurance, or deductibles may apply for each service. Your costs may depend on several things, like if your doctor or other health care provider accepts assignment, the type of facility, other insurance you may have, and the location where you get your test, item, or service. Talk to your doctor or other health care provider for more specific cost information.

Medicare may have maximum payment amounts on certain types of services and may not cover others. Your provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and if, or how much, Medicare will pay for them.

Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get cost information. TTY users can call 1-877-486-2048.

Medicare doesn’t cover:

• Room and board in assisted living facilities.
• Adult day care.
• Long-term nursing home care.
• Medical food or nutritional supplements (except enteral nutrition equipment).
• Services that help you with activities of daily living (like bathing and eating) that don’t require skilled care.

Medicare coverage other than Original Medicare

Medicare Advantage Plans (also known as Part C) Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. If you’re in a Medicare Advantage Plan or another type of Medicare health plan, your plan must give you at least the same coverage as Original Medicare, but it may have different rules and costs. Because these services may cost more if your provider doesn’t participate in your health plan, ask if your provider accepts your plan when scheduling your appointment. Read your plan materials, or call your plan for more information about your benefits.

Medicare drug coverage (Part D) of cancer-related drugs and supplies Medicare offers prescription drug coverage to everyone with Medicare, but that coverage isn’t automatic. To get Medicare drug coverage, you must join a Medicare drug plan (or join a Medicare Advantage Plan with drug coverage).

Part D covers most prescription drugs and some chemotherapy treatments and drugs. If Part B doesn’t cover a cancer drug, and you have a Medicare drug plan, your drug plan may cover it. It’s important to check with your plan to make sure your drugs are on the plan’s formulary (list of covered drugs) and to check each drug’s tier on the formulary. This affects your out-of-pocket costs. Read your plan materials, or call your plan for more information about your drug coverage. Visit Medicare.gov/plan-compare to compare plans with Medicare drug coverage.

Part D may cover these cancer drugs:

• Prescription drugs for chemotherapy only if taken by mouth
• Anti-nausea drugs
• Other prescription drugs used in the course of your cancer treatment, like pain medication

Medicare Supplement Insurance (Medigap) Policies If you have other insurance that supplements Original Medicare, like a Medigap policy or a group health plan, it may pay some of the costs for the services and supplies described in this booklet. Private companies sell Medigap policies, which help pay certain out-of-pocket costs, like deductibles, coinsurance, and copayments. For more information about Medigap, including the best time to buy a policy, visit Medicare. gov/health-drug-plans/medigap, or contact your insurance company.

Changing Medicare coverage

After getting a cancer diagnosis, speaking with your health care providers, and reviewing your current Medicare coverage, you may want to look at other health coverage options based on your needs. However, it’s important to remember that you can only change your coverage at certain times. Each year, you have a chance to make changes to your Medicare health and prescription drug coverage for the following year. Compare the plans available in your area each year to make sure you have the plan that best meets your needs. Visit Medicare.gov/plan-compare to compare plans.

For more information on joining or changing plans, visit Medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan.

Appealing coverage and payment decisions

You can file an appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare drug plan. You have the right to file an appeal if Medicare, your Medicare health plan, or your Medicare drug plan denies:

• A request for a health care service, supply, item, or prescription that you think you should be able to get
• A request for payment of a health care service, supply, item, or a prescription drug you already got
• A request to change the amount you must pay for a health care service, supply, item, or prescription drug
• Coverage or payment of all or part of a health care service, supply, item, or prescription drug you think you still need

Medicare health and drug plans also have a transition process if you’re new to the plan and taking a drug that isn’t on the plan’s formulary. The plan must let you get a 30-day temporary supply of the prescription (a 91-day supply if you’re a resident of a long-term care facility). This gives you time to work with the doctor who prescribed the drug to find a different drug that’s on the plan’s formulary. If an acceptable alternative drug isn’t available, you or your doctor can ask for an exception from the plan, and you can file an appeal if your exception is denied. Visit Medicare.gov/ appeals for more information on how to file an appeal.

For more information

• Visit Medicare.gov to:
• Learn more about what Medicare covers.
• Find and compare doctors, hospitals, and other providers.
• Find suppliers of durable medical equipment (DME) and medical supplies.
• Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
• Call your State Health Insurance Assistance Program (SHIP) to get free personalized health insurance counseling. To get the phone number for your state, visit shiphelp.org, or call 1-800-MEDICARE.

Definitions

Assignment: An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Coinsurance: An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

Copayment: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.

Deductible: The amount you must pay for health care or prescriptions before Original Medicare, your Medicare Advantage Plan, your Medicare drug plan, or your other insurance begins to pay.

Durable medical equipment (DME): Certain medical equipment, like a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home.

Exception: A type of Medicare prescription drug coverage determination. A formulary exception is a drug plan’s decision to cover a drug that’s not on its drug list or to waive a coverage rule. A tiering exception is a drug plan’s decision to charge a lower amount for a drug that’s on its non-preferred drug tier. You or your prescriber must request an exception, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.

Hospice: A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver.

Medicare Advantage Plan (Part C): A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits, with a few exclusions, for example, certain aspects of clinical trials which are covered by Original Medicare even though you’re still in the plan. Medicare Advantage Plans include:

• Health Maintenance Organizations
• Preferred Provider Organizations
• Private Fee-for-Service Plans
• Special Needs Plans
• Medicare Medical Savings Account Plans

If you’re enrolled in a Medicare Advantage Plan:

• Most Medicare services are covered through the plan
• Most Medicare services aren’t paid for by Original Medicare
• Most Medicare Advantage Plans offer prescription drug coverage

Medicare drug coverage (Part D): Part D adds prescription drug coverage to:

• Original Medicare
• Some Medicare Cost Plans
• Some Medicare Private-Fee-for-Service Plans
• Medicare Medical Savings Account Plans

These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare drug plans.

Original Medicare: Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).

Tiers: Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.

Source and further reading

Medicare Coverage of Cancer Treatment Services — Centers for Medicare & Medicaid Services. Public domain U.S. government educational material, accessed October 28, 2026. Fynoptic has selected sections, removed print navigation, and reformatted the text for this guide. The agency does not endorse Fynoptic.