Does Medicare Cover Proton Beam Therapy?

Proton beam therapy is commonly used to treat pediatric tumors, as it causes less damage to a child’s still-developing organs.

Because there is no exit radiation to cause additional damage to the tissues, proton beam treatment can also be very beneficial for treating tumors located close to the brain.

However, proton beam therapy may be beneficial for a wide variety of cancers. Your oncologist will work with patients to build a treatment plan tailored to their specific form of cancer and individual requirements.

If this is a treatment that can help you or a loved one, a common question you likely have is, “Does Medicare cover Proton Beam Therapy?” In this article, we answer the question in clear, plain English. You will also find the average costs of undergoing proton radiation therapy and other helpful information.

Does Medicare Cover Proton Beam Therapy?

The short answer is yes; Medicare will cover the cost of proton beam therapy. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your proton beam therapy. Below we look at what these are so you know what to expect.

Original Medicare

Medicare Part A and Part B do provide coverage for proton beam therapy. Original Medicare provides coverage for many cancer treatments but not all of them. Among those Original Medicare covers include proton radiation therapy.

Original Medicare provides coverage for proton beam therapy if it is considered medically necessary. Your healthcare provider must first order the treatment for Original Medicare to provide coverage.

Coverage for proton radiation therapy is provided by Medicare Part A if your proton beam therapy takes place in an inpatient setting. Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days.

Starting from the 61st day up to 90 days, Medicare Part A will still provide coverage. However, you will pay a copayment each day you are in the hospital. After 90 days, Medicare Part A will no longer provide coverage.

(Though Medicare does provide 60 lifetime reserve days. If you have them, they will still provide coverage for your hospital stay after 90 days, but with a higher copayment.)

On the other hand, most of the time, coverage for proton beam therapy is provided by Medicare Part B. It often takes place in an outpatient setting. Once approved, Medicare Part B covers 80 percent of the costs of proton radiation therapy. You will pay for the remaining 20 percent.

Medicare Advantage

Medicare Advantage plans (Medicare Part C) also provide coverage for proton beam therapy. They cover everything Original Medicare covers, as well as some additional benefits.

What it covers and how much the out-of-pocket costs vary depending on your plan’s specifics.

Medicare Part D provides coverage for other prescription drugs for your cancer treatment. Medicare Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies.

Proton Beam Therapy Costs

For those who do not have insurance, the costs for this treatment can run from $30,000 to $120,000. The American Cancer Society reports that Medicare will pay out more than $32,000 for proton beam therapy. The good news is that for most Medicare recipients, out-of-pocket costs are low so long as your deductibles and copays/coinsurance are met.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. 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.