Oral cancer, also known as mouth cancer, is a type of head and neck cancer that can develop in the lips, gums, tongue, inner cheek lining, or the roof or floor of the mouth. Treatment often involves surgery, radiation, and chemotherapy. Medicare, the federal health insurance program primarily for people aged 65 or older and certain younger people with disabilities, covers a significant portion of this treatment, but coverage is divided across its different parts. Understanding how Original Medicare (Parts A and B) and private plan options (Parts C and D) coordinate can help patients navigate the costs of oral cancer care.
Original Medicare Part B: Screening, Diagnostics, and Outpatient Treatment
Medicare Part B covers medical services necessary for the diagnosis and outpatient treatment of oral cancer. This includes initial doctor visits with specialists like oncologists and surgeons, as well as diagnostic tests such as biopsies, computed tomography (CT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans. Outpatient cancer therapies, which are a major component of treatment, are also covered under Part B. This includes chemotherapy drugs administered via infusion and external beam radiation therapy sessions. After the annual Part B deductible is met, Medicare pays 80% of the approved amount for these outpatient services, and the patient is responsible for the remaining 20% coinsurance, which does not have an annual spending limit under Original Medicare.
Original Medicare Part A: Inpatient Surgery and Facility Costs
Medicare Part A covers facility costs associated with major oral cancer surgery requiring an inpatient hospital stay. This includes expenses for the hospital room, nursing care, operating room use, and medications administered while admitted. Part A coverage is measured using a benefit period, which begins the day a patient is admitted and ends after 60 consecutive days without inpatient care. The patient must pay a deductible for each benefit period before coverage begins. After the deductible is met, Part A covers the full cost for the first 60 days of an inpatient stay, but if the stay extends beyond 60 days, the patient is responsible for a daily coinsurance amount.
Navigating the Dental Exclusion for Oral Cancer
A challenge in oral cancer treatment is the standard Medicare exclusion for routine dental care, which includes services related to the teeth or supporting structures. This exclusion has specific exceptions when dental procedures become medically necessary for the success of a covered cancer treatment. Medicare Parts A and B will cover dental services that are “inextricably linked” and “integral” to the clinical success of treatments for head and neck cancer. This includes a dental examination performed as part of the workup before a patient undergoes radiation, chemotherapy, or surgery. Additionally, dental services required to address oral complications that arise following cancer treatments are covered under these expanded rules.
Medicare Advantage (Part C) and Prescription Drug Coverage (Part D)
Medicare Advantage (Part C) is an alternative way to receive Original Medicare benefits, offered by private insurance companies. These plans must cover all services provided by Parts A and B, but they often include extra benefits, sometimes incorporating routine dental care. Part C plans typically cap the maximum amount a patient must pay out-of-pocket annually for covered medical services. Prescription drug coverage (Part D) is a separate plan that covers most self-administered oral cancer medications taken at home, which are not covered by Part B. Part D coverage involves different cost phases, including an annual deductible, an initial coverage period with copayments, and a catastrophic coverage phase. For those with Original Medicare, Medigap supplemental insurance is an option to help pay for the deductibles, copayments, and coinsurance costs that Parts A and B do not cover.