Immunotherapy is relatively new, but has already been a game changer for many people with cancer.
The first immunotherapy treatment for cancer was approved in 2011, and there are currently over 1,000 clinical trials that are researching the use of immunotherapy against different types of cancer.
Like many other cancer treatments, immunotherapy can be quite expensive. So it’s natural to be concerned about the cost.
Many people receiving cancer treatment are over 65, so they wonder: “Does Medicare and Medicaid cover immunotherapy?”
This article describes immunotherapy and what types of cancer it treats, and the two main health insurance programs for those 65 and older: Medicare and Medicaid.
It then explores whether Medicare or Medicaid covers immunotherapy treatment. So let’s dive in!
What is Immunotherapy?
Immunotherapy is a type of biological therapy that stimulates your immune system to cause a reaction. Cancer immunotherapy can work in two ways.
One is by boosting the immune system’s natural ability to fight cancer cells.
The other is by teaching the immune system to identify and destroy cancer cells. This is done by targeting specific proteins or receptors on the cancer cells, which then prevent them from slipping past the immune system’s defenses.
Immunotherapy has shown success in treating 15 different types of cancer including:
- Bladder cancer
- Breast cancer
- Cervical cancer
- Colorectal cancer
- Esophageal cancer
- Kidney cancer
- Leukemia
- Liver cancer
- Lung cancer
- Lymphoma
- Multiple myeloma
- Ovarian cancer
- Prostate cancer
- Stomach cancer
Paying for Immunotherapy
Immunotherapy, like many other types of cancer treatments, are expensive.
For instance, pembrolizumab, known as Keytruda is an immunotherapy treatment by Merck. Keytruda has FDA approval for many different types of cancer including lung cancer, cervical cancer, renal cell carcinoma, certain types of breast cancer and more.
According to the Keytruda website, the current list price per dose of Keytruda is $11,337.36 when given every 3 weeks.
When they hear the cost, most people immediately wonder how they’ll pay for that treatment. The actual cost will depend on the type of insurance you have.
Most people over 65 have coverage either through Medicare or Medicaid, which are two types of insurance coverage offered in the United States. Some people are considered ‘dual eligible’, meaning they have coverage by both Medicare and Medicaid.
Let’s go over the differences between the two and answer the question: Does Medicare or Medicaid cover immunotherapy?”
Understanding Medicare
Medicare is federal health insurance plan for people aged 65 and older, and for some people under 65 with certain conditions. There are different parts to Medicare coverage, and participants can choose the types of coverage they want.
Medicare Part A is hospital insurance. This covers the care received when you are hospitalized as an inpatient, for a stay in a skilled nursing facility after a hospitalization, home health services and hospice care.
Medicare Part B is medical insurance and covers care received in a hospital (when you’re under observation or not admitted), office visits, scans and lab tests, and some medications.
Parts A and B are joined together and are called Original Medicare.
The Medicare Part C plan, which is also called Medicare Advantage Plan, is a Medicare-approved health plan offered by a private company that has contracted with Medicare.
Medicare Advantage Plans cover most of the Part A and Part B benefits, and usually cover Medicare Part D as well. These plans may offer additional benefits that Original Medicare does not cover.
The Medicare Part D plan covers prescription drugs and is also run by private health insurance companies.
There is also Medicare Supplement Insurance, which is also known as Medigap. Medigap plans are extra insurance that you can buy from private insurance companies to fill in the gaps in Original Medicare coverage and help pay your share of out-of-pocket expenses with Original Medicare.
Medicare participants pay out of pocket for the plan and any amount of the bill that’s left over after Medicare is billed and has paid their portion. Rates vary depending on the type of coverage that’s been selected.
Understanding Medicaid
Medicaid is a joint federal and state program. This helps to cover medical services for some people with limited resources and income.
The federal government sets the overall rules for the program, but each state runs its own program, so benefits can and often do vary from state to state.
People with Medicaid coverage usually just need to pay a small copayment for some items or services, and there’s not a monthly premium fee like there is with Medicare.
Medicaid tends to cover visits to your healthcare provider, prescription drugs, and, yes, even some cancer treatments.
Under current law, if a drug manufacturer has a Medicaid rebate agreement in place with a particular state, then those state Medicaid programs must cover all of that manufacturer’s drugs.
This means that there’s a decent likelihood that your Medicaid benefits would cover many different medications and therapies to treat your cancer if your state is one that has rebate agreements in place with cancer drug manufacturers.
Coverage of Cancer Treatments by Medicare
Medicare provides coverage for immunotherapy, because it falls under the category of ‘medically necessary cancer treatment supplies, services and prescription drugs’.
So if you have Medicare, there should not be a problem getting that paid for.
I say should not, because we all know how difficult getting an insurance company to pay up sometimes can be! The out-of-pocket costs will vary depending on the plan that’s been selected.
Coverage of Immunotherapy by Medicaid
Medicaid’s approval for cancer treatments including chemotherapy, radiation treatments and immunotherapy depends heavily on the policies of each state. Each state individually decides which treatments will be approved and paid for.
Often, decision makers will look to make sure a treatment has been approved by the U.S. Food and Drug Administration (FDA) and has had success in different clinical trials to determine if that treatment will be paid for.
Sometimes a drug might be approved, but only for a certain stage and type of cancer.
It might take some extra work if the first attempt to get immunotherapy covered is denied. This is where your health care provider and their team can be of great help. They know how to handle these situations.
Sometimes additional paperwork is needed to get approval for immunotherapy to be covered. A letter may be required from your oncologist stating why immunotherapy is necessary, like if other treatments haven’t worked.
How to Check Your Medicaid Coverage
A potential hurdle to getting cancer treatment for those insured by Medicaid is that sometimes cancer treatment facilities do not accept Medicaid insurance.
This can make it harder for those with Medicaid to find a facility where their insurance is accepted first of all, and then there’s the issue of wondering if your specific treatment plan will be covered.
It’s important to understand the type of coverage you have through Medicaid. You can call your state Medicaid office and they’ll have trained staff that can answer your questions.
Your state may have a website outlining their Medicaid program, with an online portal where you can search for answers to your questions. You might be able to search for different tests and treatment types to learn what is covered on your plan.
You should have also received a Medicaid benefit handbook when you enrolled in the Medicaid program. This might have some answers for you, or can direct you to where you can find out the information.
Appealing Coverage Decisions
If Medicaid denies your immunotherapy treatment, don’t lose hope. Unfortunately, this can be common.
However, there is a process to challenge, or appeal, their decision.
First, get in touch with your healthcare provider. They’ve been through this before and can guide you on what steps to take next.
Your oncology social worker along with the financial counselor at the hospital or clinic can be a great help in telling you what is needed and what to expect.
Gathering your medical records becomes crucial at this stage. These documents prove the necessity of your treatment. Your doctor can help collect clinical trial results, blood tests, or any other evidence showing why this immunotherapy is essential for your specific type of cancer.
Then, it’s time to file an appeal. Each state has its own set of rules, but typically, you’ll need to submit a formal request.
This includes your documentation about how immunotherapy is medically necessary along with a letter from your oncologist explaining why immunotherapy is critical for successful treatment.
The goal of all of this supporting paperwork is to demonstrate how this treatment can significantly impact your fight against cancer.
If the state denies your appeal, don’t lose hope. There are financial assistance programs outside of Medicaid. Companies offering immunotherapy drugs often have programs to help patients afford their treatments.
For instance, I mentioned Keytruda earlier. This is made by Merck. They have the Merck Access Program, which has two different ways they help patients pay for their immunotherapy.
For those with private insurance, they have a co-pay assistance program, which reduces the co-pay costs for treatment.
Their patient assistance program is for those who do not have insurance, or whose insurance does not cover Keytruda. If a patient meeds medical and financial criteria, they may be eligible to get their Keytruda for free.
Final Thoughts on Navigating Coverage for Innovative Cancer Care
When dealing with a cancer diagnosis, the stress of worrying about how to pay for treatment can be overwhelming.
Your health care team should be well versed on the the major prescription drug plans and your facility will have a financial office that will check with your insurance, whether it’s private insurance, Medicare, or Medicaid to see what your out-of-pocket costs might be.
They can refer you to a patient assistance program if that type of immunotherapy manufacturer has one, and can help you understand your specific coverage for your insurance type.
Your oncology social worker and financial navigator if the facility has one will also direct you to other financial assistance programs or local organizations that help people with cancer with financial support.
The American Cancer Society may also be able to connect you with some financial resources to pay for cancer treatment as well.
Medicare and Medicaid can cover immunotherapy, but the requirements can vary from state to state with Medicaid coverage.
It’s important to discuss your options, understand your coverage, and explore every avenue for assistance.
It may take some time and energy, especially if you have to fight with the insurance company to pay the bills, or if you have to appeal a denial, but it may be well worth it to get this cutting edge type of cancer treatment paid for.
