A primary brain tumor is a brain tumor that initially grows in the brain, rather than growing elsewhere in the body and traveling to the brain. While any person of any age can be affected by a brain tumor, according to the National Center for Biotechnology Information, the median age for Glioblastoma (GBM) is 64 years old.
According to the American Brain Tumor Association, there are currently more than 700,000 people living with a brain tumor in America. However, only about 30% of them are cancerous.
The diagnosis, treatment, and recovery of a brain tumor is usually a long, taxing process. There are many medical services needed for each step. Medicare offers considerable coverage for brain tumor diagnosis, treatment, and recovery.
Diagnostic tests for brain tumors
There are several types of diagnostic tests for brain tumors. Within each type of test, there are even more variations of each specific diagnostic test. The tests that a neurologist performs to diagnose a brain tumor depends on the specifics of each patient’s case. However, these are the most common tests for diagnosing brain tumors.
- Lab work
- Neurological exam
- Scan (CT, MRI, etc.)
When Medicare covers any kind of testing, it will fall under Part B which covers approved services at 80% after deductible.
Medicare’s coverage for diagnostic tests
Medicare’s rule of thumb for diagnostic test coverage is if it is deemed medically necessary by both Medicare and the doctor, then it is covered. Diagnostic tests fall under Medicare Part B coverage. When Part B accepts coverage for a diagnostic test, Part B first applies a deductible, then covers 80% of the remaining bill.
As of 2019, the Part B annual deductible is $185. After the patient meets the deductible, Medicare covers 80% of Part B covered services. The patient is responsible for the remaining 20%.
For example, for a diagnostic test that costs $500, the patient owes $185. The remainder of the bill ($315) is split by Medicare and the patient. Medicare pays $252, and the patient pays $63. All Part B covered diagnostic tests after that are immediately subject to the 80/20 split.
Treatment for brain tumors
Once diagnosed, the neurologist creates a treatment plan for the brain tumor. Again, Medicare covers the treatment if it is deemed medically necessary by both Medicare and the doctor to treat the brain tumor. Common forms of treating a brain tumor are:
- Clinical trials
- Proton therapy
- Radiation therapy
- Stereotactic radiosurgery
Medicare’s coverage for treatments
Most of these forms of treatments are also subject to Part B coverage. However, medications are a little trickier. Medications can be subject to Part A, Part B, or Part D coverage.
For example, chemotherapy and medications administered to a patient by a trained medical worker or via durable medical equipment are covered under Part B. However, if the patient is an inpatient in the hospital, Part A may cover some medications. Other prescription medications like oral pills are covered under Part D.
Part A covers hospital stays and some services while the patient is in the hospital. Part A has a $1,364 deductible in 2019 and can be owed more than once per year if the patient has multiple inpatient hospital stays. This deductible covers the first 60 days in the hospital.
Chimeric Antigen Receptor T-cell therapy
Chimeric Antigen Receptor T-cell (CAR T-cell) therapy is another form of treating brain tumors. T-cells fight infections that attack a person’s immune system. CAR T-cell therapy takes those T-cells and genetically modify them so they can attack the cancerous brain tumor better.
Recently, the Centers for Medicare and Medicaid Services decided to cover CAR T-cell therapy for Medicare beneficiaries diagnosed with certain types of cancer. According to EBC’s recent press release, if the person has been diagnosed with, “certain types of non-Hodgkin lymphoma, and B-cell precursor acute lymphoblastic leukemia,” CAR T-cell therapy is covered by Medicare.
At this point, Medicare has not said whether or not Part B will cover CAR T-cell therapy for brain cancer specifically. With that said, it’s important for patients to always ask their physicians, “Is the treatment you are recommending covered by Medicare?”
This ensures that the doctor’s office using the correct coding on its billing so that Medicare can cover the service.
Medication coverage for brain tumors
Prescription medication is a big part of treating brain tumors. Medicare Part D plans all follow the same structure. Part D plans are required, by Medicare, to cover at least two medications from each drug class. This means doctors have a couple of options when prescribing medicine for a certain condition or illness.
Each Part D plan is created and sold by private insurance carriers. The carriers of the plans get to decide costs, such as premiums, copays, deductibles, and more. As of 2019, the Part D deductible ranges from $0 to $415. Once the deductible is met, the beneficiary pays copays or coinsurance for each prescription. The cost is determined by which the tier of the drug.
Medicare beneficiaries should shop their Part D plan every year during the Annual Election Period (October 15th – December 7th). They should enroll in a plan that covers all or most of their prescriptions for an affordable price.
Recovery for brain tumor treatment
Some treatment methods may require an inpatient hospital stay. If the patient is admitted to the hospital for at least three days, the doctor may recommend the patient finishes his recovery at a skilled nursing facility.
The Part A deductible mentioned earlier covers the first 20 days in a skilled nursing facility. If the patient needs to stay past 20 days, there will be a daily copay around $170 each day spent in the facility past day 20.
However, if the patient has a Medigap plan that covers the Part A deductible and coinsurance, these costs would be covered at 100%. Medigap plans can also cover the Part B coinsurance mentioned earlier.
People who have been diagnosed with a brain tumor prior to being on Medicare should consider enrolling in a Medigap plan during their one-time Medigap open enrollment window. If Medicare beneficiaries miss this window, they could be denied coverage down the road. Diagnosing and treating a brain tumor is expensive.
Medigap vs Medicare Advantage
A Medigap plan (also known as a Medicare supplement) is very different from a Medicare Advantage plan. A Medigap plan can protect those with a brain tumor from spending thousands of dollars out-of-pocket. Having Original Medicare coupled with a Medigap plan, allows the patient to choose where to get treatment. This type of coverage can be used anywhere in the U.S. where Medicare is accepted.
Alternatively, with a Medicare Advantage plan, a patient receiving cancer treatment could be left paying high out-of-pocket costs due to frequent copays and coinsurance. Additionally, Medicare Advantage plans have networks of doctors. The patient is restricted to a specific group of doctors for cancer treatment in order to receive coverage from the plan.
Some people opt for Medicare Advantage plans when they age into Medicare due to the low (sometimes $0) monthly premiums. A Medicare Advantage plan is a better alternative to just having Original Medicare alone, but it does not hold the same weight as a Medigap plan when it comes to coverage for cancer treatment.