Radiation treatment is covered by Medicare when a doctor deems it medically necessary. Coverage extends to both external beam radiation, which targets the tumor from outside the body, and brachytherapy, which involves placing radioactive sources directly inside or near the cancerous area. The specific part of Medicare that covers the service depends on where the treatment is delivered.
Outpatient Coverage Through Medicare Part B
Most radiation therapy treatments are delivered in an outpatient setting, such as a freestanding clinic or a hospital’s outpatient department. These services are covered under Medicare Part B, which pays for the medical services and supplies needed to plan and deliver the radiation. This includes the initial consultation with the radiation oncologist and the sophisticated treatment planning process.
The planning stage involves imaging, such as CT scans, and complex computer modeling to precisely map the tumor and surrounding healthy tissue. Part B pays for the delivery of advanced techniques like Intensity-Modulated Radiation Therapy (IMRT) and Three-Dimensional Conformal Radiation Therapy (3D-CRT). These methods use computer-controlled linear accelerators to shape the radiation beams, maximizing the dose to the tumor while reducing exposure to adjacent organs.
Outpatient brachytherapy, which involves placing radioactive sources within the body, is also generally covered by Part B. This component covers the professional services of the physician and the technical components provided by the facility. High-dose rate (HDR) brachytherapy, which delivers a concentrated dose over a short time, is a covered outpatient service.
Inpatient Coverage Through Medicare Part A
Medicare Part A covers radiation treatment only when the beneficiary is formally admitted to a hospital as an inpatient. This is typically reserved for complex procedures or when the patient’s condition requires close monitoring. Certain intricate brachytherapy procedures or those bundled with a surgical stay may fall under Part A coverage.
Part A covers the facility costs associated with the hospital stay, including the room, meals, nursing services, and the cost of the radiation treatment itself. Coverage is organized around a benefit period, which begins the day a person enters a hospital and ends when they have been out of a hospital or skilled nursing facility for 60 days in a row.
Managing Deductibles and Coinsurance
Original Medicare (Parts A and B) requires the patient to share the cost of radiation treatment through deductibles and coinsurance. Under Part B, which covers most radiation services, the beneficiary must first meet an annual deductible. Once the deductible is satisfied, Medicare generally pays 80% of the Medicare-approved amount for the service, and the patient is responsible for the remaining 20% coinsurance.
Since a typical course of radiation therapy involves multiple daily sessions over several weeks, the 20% coinsurance can quickly accumulate into a substantial out-of-pocket expense. Many beneficiaries choose to enroll in a Medicare Supplement Insurance plan, also known as Medigap, to help manage these costs. Medigap policies are designed to cover the cost-sharing gaps in Original Medicare, including the Part B coinsurance.
Coverage Under Medicare Advantage and Novel Therapies
Medicare Advantage (Part C) plans are required by law to cover at least the same services as Original Medicare (Parts A and B), which includes medically necessary radiation treatment. However, these plans, offered by private insurance companies, can structure their cost-sharing differently, often using copayments instead of the 20% coinsurance and setting their own out-of-pocket maximums. Advantage plans may also require beneficiaries to use providers within a specific network and often mandate prior authorization for radiation oncology services.
Advanced radiation delivery techniques, such as Stereotactic Body Radiation Therapy (SBRT) and Proton Beam Therapy (PBT), are generally covered if they meet the standard of medical necessity. PBT, which uses protons to deliver a focused dose of radiation while sparing surrounding healthy tissue, is typically covered when traditional photon-based radiation therapy cannot adequately spare adjacent critical organs. While both Original Medicare and Advantage plans cover these novel therapies, research suggests that Advantage beneficiaries may be less likely to receive some of the most advanced forms of radiation compared to those with Original Medicare.