Medicare covers a wide range of services for the treatment and diagnosis of bladder cancer when received on either an inpatient and outpatient basis.
When a person receives a cancer diagnosis, it can be a challenging time. Aside from medical and emotional care, financial support can be vitally important.
Medicare has a comprehensive range of cancer-related benefits available, with additional support options to help with out-of-pocket expenses.
In this article, we discuss bladder cancer, how Medicare covers treatments and services, and resources that may provide more help.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers medically necessary treatment options for bladder cancer, including:
- targeted therapy
- intravesical therapy
Sometimes, a doctor may plan treatment more often than Medicare will approve, or they may order services that Medicare does not cover.
In these cases, a person may have to pay some or all of the costs out of pocket.
For someone with an average risk of developing bladder cancer, there are currently no preventive screenings that would increase an individual’s chance of survival.
Some healthcare providers screen people who have a high risk of bladder cancer. These include people who:
- have had bladder cancer before
- have an irregularity in the bladder that has been present since birth
- are exposed to certain chemicals at work
Screening can include examining a person’s urine under a microscope to look for blood and cancer cells.
Some tests also look for tumor markers. These tests look for substances in the urine that indicate there may be cancer cells present.
Medicare Part A covers medically necessary cancer treatments that take place while a person is admitted to the hospital. This includes surgical procedures, chemotherapy, and radiation treatments.
Part A also covers necessary skilled nursing facility care, hospice, and home health care. If a person is enrolled in an eligible clinical study, Part A covers some inpatient costs.
Medicare Part B covers tests and treatments when a person is not required to stay in the hospital. The treatments must be medically necessary and they must be standard medical treatments.
These can include:
- doctor visits
- durable medical equipment (DME)
- many intravenous chemotherapy drugs
- outpatient surgery
- nutritional counseling
- mental health services
- feeding pumps
Several different types of surgeries may help treat bladder cancer, and which type a doctor chooses depends on the type and spread of cancer.
Transurethral resection of bladder tumor (TURBT)
This surgery may be used for diagnostic testing. It can also treat early-stage bladder cancer.
If the cancer is invasive, some or all of the bladder is removed using this surgery.
If the whole bladder is removed, the body needs another way to store urine. There are three different types of reconstruction that can be done after a total cystectomy. These include:
- incontinent diversion
- continent diversion
After a diagnosis of bladder cancer is confirmed, a person’s treatment is covered except for the out-of-pocket expenses.
Some medication that does not specifically relate to cancer treatment, such as pain management drugs or anti-emetics, may not be covered unless a person has coverage for prescription drugs through Medicare Part D.
Part D policies, also known as prescription drug plans (PDPs) are administered by private insurance companies and covered medicines may vary. If a person disagrees with a coverage decision, they have the right to appeal.
There are standard out-of-pocket costs for Medicare parts A and B, some of which are dependent on a benefit period.
A benefit period begins when a person is admitted to the hospital and ends when they have not received any services from a hospital for 60 days or more.
In 2020, Medicare Part A has:
- a deductible of $1,408 per benefit period
- $0 copayment for the first 60 days spent in the hospital
- $352 copayment for days 61-90 per benefit period
Most people pay the standard Medicare Part B premium of $144.60 in 2020, with an annual deductible of $198. After a person has paid their deductible, there is a 20% coinsurance for all eligible services.
Bladder cancer is seen mostly in older adults, and on average, a person is diagnosed at 73 years old.
A person’s bladder is a hollow organ in the lower part of the pelvis. The organ is made up of muscle and stores urine from the kidneys.
Cancer cells are cells that grow uncontrollably. When these cells start growing in the bladder, it is called bladder cancer. In time they may spread to other parts of the body.
Bladder cancer can start in different parts of the bladder. The most common type starts in the cells that line the bladder. Other types are:
- squamous cell
- small cell carcinoma
Bladder cancer can be invasive or non-invasive. Invasive cancers grow into the deep layers of the bladder wall and are more likely to spread.
Non-invasive cancers grow only on the inner wall of the bladder.
Some individuals may have a higher risk of developing bladder cancer than others due to specific factors. A risk factor is something that increases the possibility of a person developing bladder cancer.
Having a risk factor does not mean an individual will get the disease, but being aware of risk could be helpful.
Risk factors for bladder cancer include:
- exposure to certain industrial chemicals
- some medicines or herbal supplements
- arsenic in drinking water
- not drinking enough water each day
- chronic bladder infections
- an irregularity within the bladder that has been present since birth
- family history of bladder cancer
- radiation or chemotherapy for another cancer
In most cases, a person will have symptoms of bladder cancer, which include blood in the urine, pain with urination, using the bathroom more often, or having lower back pain.
A person may also have a lab test for another reason that shows they may have bladder cancer.
There are different programs that may support a person with the costs associated with bladder cancer.
A person may get help with out-of-pocket expenses by enrolling in a Medigap plan, which is Medicare supplemental insurance.
These policies may help to pay copayments, coinsurance, and the Part A deductible. A person cannot have a Medicare Advantage plan and a Medigap plan at the same time.
A person with limited resources may qualify for Medicaid.
This program is for those with limited income and resources, and eligibility information is available on the Medicaid website.
Medicare savings programs
A person who does not qualify for Medicaid may qualify for help from one of four Medicare savings programs that help to pay premiums and other costs. These include:
- Qualified Medicare Beneficiary program
- Specified Low-Income Medicare Beneficiary program
- Qualifying Individual program
- Qualified Disabled and Working Individuals program
People who qualify for Medicaid or one of these savings programs may also get Extra Help. This program helps pay for prescription drugs.
A diagnosis of bladder cancer can be challenging. Medicare can help pay for many of the costs relating to diagnosis and treatment.
Medicare Part A pays for hospital, hospice, home health, and skilled nursing facility care. Medicare Part B pays for treatment and services outside the hospital.
Individuals may have out-of-pocket expenses, such as deductibles, premiums, copayments, and coinsurance.
A person may find help paying these costs through Medigap plans, Medicaid, or with a Medicare savings program.
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