Breast cancer is a subject that women are prepared to discuss because it affects roughly one in 10 women throughout their lives. Men, on the other hand, face this disease far more infrequently. In 2018, roughly 2,550 cases of male breast cancer diagnoses occurred and 480 deaths.
A breast cancer diagnosis isn’t easy for anyone—even more so for males who don’t know if Medicare will cover a typically female disease. Ultimately, however, Medicare covers male breast cancer very similarly to the way it covers breast cancer in women.
Original Medicare and Breast Cancer
To be upfront – Medicare won’t cover preventative mammograms for men, although Medicare will cover diagnostic mammograms for both women and men.
Part A Medicare will cover men the same way it covers women. Your Part A benefits under Original Medicare covers your inpatient hospital stays. The Part A deductible will cover 60 days of inpatient hospital care at 100 percent but after the 60-day mark, you’ll have to pay a daily copay.
If surgery is the treatment course for your male breast cancer diagnosis and you are in the hospital for at least three days, your Part A benefits will also cover 20 days in a skilled nursing facility during your recovery. Hospice care is also covered under Part A at 100 percent.
If your course of treatment requires outpatient cancer treatments such as outpatient surgery, MRIs, radiation, chemotherapy and doctor visits, your Original Medicare Part B will pay its share of those expenses. Once you have met your annual deductible, Part B will then pay 80 percent of your outpatient costs and you’ll pay the remaining 20 percent.
There is a monthly premium that everyone must pay for Part B benefits. As of 2019, the monthly premium for Part B is $135.50. However, for Americans that have worked in America for at least ten years and paid FICA taxes, Part A is premium-free.
Medicare Part D Coverage
This part of Medicare provides coverage for your retail prescription medications. Part D is additional coverage sold by private insurance carriers and will cover any self-administrable drugs. Although each plan is different as far as which drugs are covered, the structure of these plans is the same. Every Part D plan has an initial co-payment stage, deductibles, a coverage gap and catastrophic coverage.
Part D does not cover prescription drugs administered by a doctor or injections given in a clinic. These fall under Part B coverage. Part B also is responsible for covering drugs used with durable medical equipment (DME).
Medicare Coverage of Genetic Testing
In certain circumstances, Medicare will cover hereditary cancer genetic counseling and testing for those already diagnosed with cancer. Medicare will not cover any genetic testing for someone who hasn’t already been diagnosed with cancer.
The following criteria must be met to qualify for Medicare coverage of genetic testing:
Criteria for the patient:
Relapsed, recurrent, refractory, metastatic or advanced stage III or IV cancer
No previous test using the same genetic test for the same diagnosis
The patient has decided to pursue further cancer treatment such as chemotherapy
Criteria for the lab/genetic test:
FDA clearance or approval as a companion diagnostic
A cleared or approved drug/treatment in the patient’s cancer by the FDA
Specific treatment options listed in the results and provided to the physician managing the patient’s cancer
Medicare coverage is similar for both men and women for breast cancer treatments and diagnosis. As previously mentioned, Original Medicare only covers 80 percent of medical expenses, so to be better prepared for the remaining 20 percent, many patients buy additional supplemental coverage – especially cancer patients. If you ever have questions about your coverage or options for a plan that is right for you, consult an expert like an insurance broker that specializes in Medicare.