What is Medicare?
Medicare is a public health insurance program administered by the Centers for Medicaid and Medicare Services. It began in 1966 under the Social Security Administration.
All Americans over the age of 65 are generally eligible to receive Medicare coverage. Because the vast majority of people diagnosed with mesothelioma are age 65 and older, most are receiving Medicare medical benefits.
Some mesothelioma patients rely on Medicare alone for health care coverage, while others have Medicare in addition to private insurance plans. A 2021 research study published in the Journal of Thoracic Disease showed that patients with Medicare or private insurance have improved survival rates compared to patients with Medicaid or no insurance.
Types of Medicare and Coverage
There are four main components to Medicare coverage that impact what will be included or excluded from each person’s coverage.
Medicare Part A and Part B, also known as Original Medicare, covers hospital insurance and medical insurance, respectively.
Some people are automatically enrolled in Medicare Part A when they begin receiving Social Security benefits. Others have to sign up for it, which you can do online through the Social Security Administration website. Medicare Part B is optional coverage that is purchased from the federal government.
Other optional plans include Part C, which goes through private insurers who work with Medicare, and Part D, which includes prescription drug coverage.
What Do the Different Parts of Medicare Cover?
- Medicare Part A: Inpatient hospital stays, nursing home care, hospice care and some home health care. You will not pay a premium for Medicare Part A if you or your spouse has paid Medicare taxes for at least 10 years.
- Medicare Part B: Certain doctors’ services, outpatient care, medical supplies and preventative services. This plan requires a premium, which is usually paid monthly and deducted from your Social Security benefit check.
- Medicare Part C: Also known as Medicare Advantage Plans, this is offered by private insurance companies that contract with Medicare. Part C provides Part A and Part B benefits along with emergency and urgent care, vision services, hearing services, dental services and Medicare Part D prescription drug coverage.
- Medicare Part D: This plan provides prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans and Medicare Medical Savings Account Plans.
What Does Medicare Cover for Mesothelioma?
If you are enrolled in Original Medicare (Part A and Part B), certain aspects of mesothelioma treatment may be covered.
Allowable charges may include:
- Doctor visits
- Scans and tests
- Radiation therapy
- Nursing home care or hospice care
Generally, Part A Medicare covers inpatient hospital care for mesothelioma patients, while Part B covers most of the treatment you may receive on an outpatient basis.
Part A Coverage for Mesothelioma
- Inpatient care in hospitals
- Hospice care services, including palliative care
- Home health care services
Part B Coverage for Mesothelioma
- Office visits to a primary care physician or a specialist
- Most IV medications such as chemotherapy
- Laboratory costs, including blood work and X-rays
- Medical equipment such as wheelchairs and walkers
- Outpatient physical therapy
- Mental health care
- Ambulance services
Medicare Advantage Plans (Part C) cover everything in Part A and B with access to services not available through Original Medicare. Part C coverage that may benefit mesothelioma patients include emergency and urgent care, health and wellness programs and Medicare Part D prescription drug coverage.
Does Medicare Cover Immunotherapy Treatments?
Because most immunotherapy treatments for mesothelioma are only available through clinical trials, the cost of drugs such as pembrolizumab (Keytruda) and nivolumab (Opdivo) are usually covered by the clinical trial.
Pharmaceutical companies may also cover the costs of the drugs under compassionate-use programs such as the Merck Access Program.
Does Medicare Cover All the Costs of Treatment?
Medicare has contracts with hospitals on how much they are willing to pay out for certain services. This is why some hospitals and doctors do not accept Medicare patients — because they are not able to charge the full amount they typically would.
For example, a person with private insurance may be charged full price for a procedure whereas Medicare may only allow the hospital to charge 80 percent.
Medicare also typically requires a 20 percent copay from the patient. A patient navigator or social worker at the cancer treatment center can answer specific questions about Medicare, private insurance coverage and out-of-pocket expenses.
How Does Medicare Work with Other Insurance?
Many people with Medicare also have health insurance coverage from a private company. In this case, a “coordination of benefits” will figure out which plan is responsible for paying claims first.
The primary insurer, or “primary payer,” will pay up to the limits of its coverage and send the rest to the “secondary payer.” The secondary payer — which can be Medicare — may not pay all the uncovered costs.
If your private insurance is the secondary payer, you may need to enroll in Medicare Part B before it will pay the remaining balance. In some cases, Medicare may cover costs that another insurer may be responsible for. This is called a conditional payment.
Conditional payments must be repaid to Medicare if you get a settlement or jury award in a mesothelioma lawsuit or if you receive an award or other payment later.
Does Medicare Take Liens on Mesothelioma Settlements?
The Centers for Medicare and Medicaid Services can assert the recovery of Medicare payments against settlements, judgments, payments or awards involving environmental hazards — including asbestos exposure. This is known as a lien.
Awards from an asbestos bankruptcy trust claims and mesothelioma lawsuits may be subject to a lien.
A qualified mesothelioma lawyer can help you understand what may be subject to a Medicare lien and negotiate the amount of a lien repayment.