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Cancer is one of the most serious medical conditions out there. One of the ways to battle cancer in our bodies is through different kinds of immunotherapy. And one of the options includes a therapy called Chimeric Antigen Receptor therapy, or CAR-T therapy.
If you or a loved one could benefit from this type of treatment, you likely have the question “does Medicare cover CAR-T Therapy?”
In this article, we answer that question in clear, plain English. You will also find the average costs of CAR-T Therapy for those who don’t have insurance.
Does Medicare Cover CAR-T Therapy?
The short answer is yes; Medicare will cover the cost of CAR-T therapy. But this is not true 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your CAR-T therapy. Below we look at what these conditions are so you know what to expect.
Original Medicare Coverage
Original Medicare (Medicare Part A and Part B) provides coverage for CAR-T therapy. Original Medicare provides coverage for your CAR-T therapy if it is considered medically necessary. Your healthcare provider must first order the operation for Original Medicare to provide coverage.
Medicare Part A Coverage for CAR-T Therapy
Coverage for immunotherapy for cancer is provided by Medicare Part A if it takes place in an inpatient setting. Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days.
For days 61 to 90, Medicare Part A will still provide coverage. However, you will pay a copayment each day your are in the hospital. After 90 days, Medicare Part A will no longer provide coverage.
However, Medicare Part A does provide 60 lifetime reserve days that you could use. If you have them, they will still provide coverage for your hospital stay after 90 days, but you will have to pay a copayment.
Medicare Part B Coverage for CAR-T Therapy
On the other hand, coverage for immunotherapy for cancer is provided by Medicare Part B if it takes place in an outpatient setting.
Once approved, Medicare Part B covers 80 percent of the costs of immunotherapy for cancer. You will pay for the remaining 20 percent.
Coverage for CAR-T therapy is usually provided by Medicare Part B, as it often takes place in an outpatient setting. Medicare Part B provides coverage for CAR-T therapies if they take place in a healthcare facility that is enrolled in the FDA-risk evaluation and mitigation strategies for FDA-indications.
Original Medicare also provides coverage for other immunotherapies for cancer. Your healthcare provider must first order the operation for Original Medicare to provide coverage.
Part C and Part D Coverage for CAR-T Therapy
Medicare Advantage plans (Medicare Part C) also provide coverage for immunotherapy for cancer. They cover everything Original Medicare covers, as well as some additional benefits.
However, exactly what it covers and the out-of-pocket costs will vary depending on the specifics of your plan.
Medicare Part C plans that include prescription drug plans will also provide coverage for medications your healthcare provider will prescribe to you. Medicare Part D plans also provide coverage for immunotherapy medications.
How Much Does CAR-T Therapy Cost?
CAR-T treatment may cost somewhere from $350,000 to $500,000. This depends on the exact drug used.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series including: Does Medicare Cover Cornea Transplants?