Medicare covers medically necessary treatment of breast cancer. This includes a mastectomy or a double mastectomy, as well as reconstruction and prosthesis surgery.
Original Medicare Part A covers inpatient breast cancer surgery, while Part B covers outpatient surgery and treatment.
Medicare Advantage, also known as Part C, is an alternative to Original Medicare and provides all the coverage of Parts A and B under one plan, including additional coverage.
Out-of-pocket expenses exist with both Original Medicare and Medicare Advantage plans.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
If a person has cancer in both breasts, Original Medicare and Medicare Advantage provide broad coverage for a double mastectomy.
The coverage also includes breast reconstruction and prosthesis implantation, in addition to nonsurgical treatments, such as chemotherapy and radiation.
Some people who do not have breast cancer choose to have a prophylactic double mastectomy, also known as a preventive double mastectomy. This means they undergo surgery to prevent the occurrence of the disease.
These individuals have a high risk of breast cancer due to a personal or family history of cancer. They also may have a genetic condition that increases their likelihood.
Medicare may or may not cover a prophylactic mastectomy, and coverage is reviewed on an individual basis.
Original Medicare Part A is hospitalization insurance, while Part B is medical insurance. Below are the coverage and out-of-pocket costs of each.
Part A
Coverage includes:
- inpatient hospital stays and inpatient cancer treatment
- home healthcare, such as physical therapy, following a hospital stay
- skilled nursing facility stay, after a 3-day related hospital stay
- surgical implantation of a breast implant after a mastectomy, if carried out on an inpatient basis
Services that are not covered include long-term nursing home care and cosmetic surgery.
Part A out-of-pocket costs include:
- $1,676 deductible for each benefit period
- $0 coinsurance for the first 60 days of a benefit period
- $419 coinsurance for days 61 to 90 of a benefit period
- $838 coinsurance for days 91 to 150 while using 60 lifetime reserve days
- all costs after day 150
A benefit period starts the day a person enters a hospital and ends the day after they have been out of the hospital for 60 consecutive days.
Lifetime reserve days are additional days Medicare will cover when a person is in the hospital longer than 90 days. A person has 60 total reserve days during their lifetime. For each reserve day, Medicare covers all costs accept for the daily coinsurance fees.
Part B
Part B covers treatment and services that someone receives on an outpatient basis. This includes:
- many chemotherapy drugs administered in an outpatient clinic or doctor’s office
- some oral chemotherapy
- doctor visits
- diagnostic tests, such as X-rays
- radiation therapy administered in an outpatient setting
- medical equipment, such as walkers or wheelchairs
- outpatient surgeries
- in some instances, a second opinion for non-emergency surgery and a third opinion if the first and second opinions differ
- external breast prostheses, such as a post-surgical bra
Part B out-of-pocket costs include:
- $185 monthly premium
- $257 annual deductible
- 20% coinsurance
Medicare Advantage plans provide the same coverage as Parts A and B for mastectomy and breast cancer care.
Unlike Original Medicare, they often include prescription drug coverage. A person with a plan may need to use in-network doctors and hospitals to get lower costs.
Costs of Medicare Advantage include deductibles, copayments, coinsurance, and monthly premiums, all of which differ among plans.
Medicare Advantage plans have an annual cap on out-of-pocket costs.
Part D plans provide prescription drug coverage that includes most chemotherapy medications. If a person’s Part B plan does not cover them, their Part D may.
An individual with Original Medicare is eligible to buy a Part D plan. Each plan has a formulary or list of covered drugs, so a person may wish to check their plan to see if it includes their prescription drugs.
As with Medicare Advantage, the plans include deductibles, copayments, coinsurance, and monthly premiums, all of which vary.
Medigap, also known as Medicare supplement insurance, helps with uncovered costs associated with Parts A and B.
The plans are available for people with Original Medicare only.
Medigap plans have a monthly premium and depending on the plan, they provide 50 to 100% of certain uncovered Parts A and B costs.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Breast cancer involves the abnormal growth of cells in the breast. According to the Centers for Disease Control and Prevention (CDC), it is the
The disease can start in any part of the breast,
- lobules, which are the glands that produce milk
- ducts, which are the tubes that transport milk to the nipple
- connective tissue, which is the fatty and fibrous tissue that holds the parts of the breast together
Most breast cancers start growing in the ducts. The cancers can spread from the breast to other parts of the body through lymph vessels and blood vessels. If this happens, it is called metastatic breast cancer.
Treatment depends on the type of cancer and the extent of its spread. It can involve one or more of
- surgery to cut out the cancer
- chemotherapy medication to shrink or kill cancer cells
- radiation therapy in which high-energy X-rays kill cancer
- hormonal therapy to stop cancer cells from getting the hormones needed to grow
- biological therapy, which is an approach that helps the body’s immune system fight cancer cells
A mastectomy involves the surgical removal of the entire breast.
There are three types of this operation:
- total or simple mastectomy
- modified radical mastectomy
- (nipple-sparing) mastectomy
Total or simple mastectomy
A total mastectomy is the removal of the entire breast. It does not include the removal of lymph nodes in the underarm area or muscles underneath the breast.
A doctor may recommend this procedure for people with multiple cancers or large areas of cancer in their ducts, or people with a high risk of breast cancer who want to undergo prophylactic surgery.
Modified radical mastectomy
A modified radical mastectomy involves the removal of both breasts’ lymph nodes in the underarm area. It does not include the removal of the chest muscles underneath the breast.
Doctors advise this procedure for people with invasive breast cancer.
Nipple-sparing mastectomy
As the name implies, a subcutaneous, or nipple-sparing, mastectomy involves the removal of an entire breast with the exception of the nipple.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Original Medicare and Medicare Advantage provide coverage for a double mastectomy, along with other breast cancer treatments, such as chemotherapy, radiation, and surgical implantation of a prosthesis.
Costs associated with both Medicare programs include deductibles, copayments, and coinsurance. If a person with Original Medicare has a Medigap plan, it pays some of these expenses.
Someone thinking of having a double mastectomy may wish to check their Medicare plan for details on coverage and costs.
