What Medicare will not cover in 2026 | The American Legion

What Medicare will not cover in 2026 | The American Legion

What Medicare Won't Cover in 2026: Critical Gaps for Prostate Cancer Patients

BLUF (Bottom Line Up Front)

Original Medicare (Parts A and B) excludes numerous services crucial for prostate cancer patients, including routine dental care, most vision services, hearing aids, outpatient prescription drugs, adult incontinence supplies, long-term care, and most home health assistance. These coverage gaps can create significant out-of-pocket costs for cancer patients managing treatment side effects and quality-of-life issues. While Medicare Advantage plans may fill some gaps, they impose network restrictions that can limit access to specialized cancer care and top-ranked hospitals—a critical concern for cancer patients. Health Savings Account funds accumulated before Medicare enrollment remain available tax-free to cover many uncovered expenses. Patients should carefully evaluate Medicare Advantage versus original Medicare with Medigap supplemental insurance based on their individual treatment needs and priorities. The years between ages 55 and 65 represent a critical window to establish and maximally fund an HSA—an opportunity that closes permanently at Medicare enrollment.

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Understanding Medicare's Coverage Limitations

For prostate cancer patients navigating the Medicare system in 2026, understanding what original Medicare doesn't cover is as important as knowing what it does. While Medicare Parts A and B provide substantial coverage for cancer treatment itself—including hospitalizations, physician services, radiation therapy, and many diagnostic tests—several critical services fall outside the program's scope, leaving patients to cover costs out-of-pocket or through supplemental insurance.

The monthly Part B premium for 2026 stands at $202.90 for most beneficiaries, with additional deductibles and copayments required unless patients have supplemental coverage. The Part B annual deductible is $283, and the Part A deductible is $1,736 per benefit period. However, many preventive services remain fully covered without cost-sharing.

Critical Coverage Gaps for Prostate Cancer Patients

Prescription Medications: A Major Concern

Perhaps the most significant gap for prostate cancer patients is that original Medicare (Parts A and B) does not cover outpatient prescription drugs. This creates an important distinction between different types of cancer medications:

Injectable ADT Medications (Covered Under Part B):

Physician-administered injectable androgen deprivation therapy (ADT) agents are covered under Medicare Part B as medical benefits, not Part D prescription drugs. These include:

• Leuprolide acetate (Lupron, Lupron Depot, Eligard) - HCPCS codes J9217, J9218, J9219
• Degarelix (Firmagon) - HCPCS code J9155
• Goserelin (Zoladex) - HCPCS code J9202
• Triptorelin (Trelstar) - Part B covered
• Histrelin (Vantas, Supprelin LA) - HCPCS code J9226

These injections are administered in a physician's office and billed through Medicare Part B. Under original Medicare, patients typically pay 20% coinsurance after meeting the Part B deductible. With a Medigap Plan G, patients generally pay nothing out of pocket.

Oral Medications (Require Part D Coverage):

Oral prescription medications require separate Medicare Part D prescription drug coverage, including:

• Oral antiandrogens: enzalutamide (Xtandi), apalutamide (Erleada), darolutamide (Nubeqa), relugolix (Orgovyx)
• Chemotherapy agents prescribed for home use
• Pain management medications
• Bone health medications taken orally

To address this gap, patients must enroll in a separate Medicare Part D prescription drug plan. Part D plans vary significantly in their formularies, tier structures, and out-of-pocket costs. The 2026 provisions cap annual out-of-pocket spending at $2,100 for Part D enrollees (up from $2,000 in 2025), providing important cost protection for patients on expensive cancer medications. The maximum Part D deductible for 2026 is $615.

Important Note: Medicare Part D covers only prescription medications, not medical devices. Over-the-counter hearing aids, incontinence supplies, and similar items are not covered by Part D, regardless of whether they might help manage treatment side effects.

Incontinence Supplies: An Overlooked Burden

Medicare does not cover adult diapers or other incontinence supplies, classifying them as personal hygiene items rather than medical necessities. This presents a substantial challenge for prostate cancer patients, as urinary incontinence is a common side effect of:

• Radical prostatectomy (affecting 5-70% of patients depending on surgical technique and definition used)
• Radiation therapy (affecting 2-16% of patients)
• Advanced disease progression

The monthly cost of incontinence supplies can range from $50 to over $200 depending on severity, creating an ongoing financial burden that many patients don't anticipate when planning for treatment. Annual costs can reach $600-$2,400, representing a significant expense over the course of treatment and recovery.

Dental Care: Important for Overall Health

Original Medicare does not cover routine dental care, including checkups, cleanings, X-rays, fillings, root canals, extractions, or dentures. This gap has particular significance for cancer patients because:

• ADT has been associated with increased risk of periodontal disease and tooth loss in some studies
• Chemotherapy can cause oral complications including mucositis and increased infection risk
• Poor oral health can complicate cancer treatment and recovery
• Bisphosphonates and denosumab used for bone metastases carry risk of osteonecrosis of the jaw, making preventive dental care crucial before starting these medications

Patients may need to budget $300-500 annually for routine dental care or purchase separate dental insurance.

Vision Care Limitations

Medicare does not cover routine eye exams, eyeglasses, or contact lenses except following cataract surgery. However, it does cover medically necessary eye care for conditions like glaucoma and macular degeneration.

For prostate cancer patients, this gap is relevant because:

• Some cancer treatments may affect vision
• Aging patients commonly need vision correction
• ADT may potentially affect eye health, though research is ongoing
• Quality of life during treatment depends on ability to read, drive, and maintain independence

Hearing Services: Communication Matters

Original Medicare will not pay for routine hearing exams or hearing aids, though it may cover hearing-and-balance exams if medically necessary (ordered by a physician for potential medical treatment).

Over-the-Counter (OTC) Hearing Aids: Since the FDA authorized OTC hearing aids in 2022, these devices have become available at lower costs (averaging $200-$1,000 per pair) compared to prescription hearing aids (averaging $3,300 per pair). However, Medicare does not cover OTC hearing aids, and Medicare Part D does not cover them either, as Part D covers only prescription medications, not medical devices.

This can affect cancer patients' quality of life and ability to communicate effectively with healthcare providers about their treatment. Hearing aids can cost $1,000-6,000 per pair for prescription devices, representing a significant expense for patients on fixed incomes. Some chemotherapy agents may affect hearing, making this coverage gap particularly relevant for certain patients.

Legislative Update: The Medicare Hearing Aid Coverage Act (H.R. 500) was introduced in the 119th Congress and would remove Medicare's exclusion of hearing aids and exams from coverage, with implementation potentially beginning January 1, 2026 if passed. However, as of February 2026, this legislation has not been enacted into law.

Long-Term and Home Care: Planning for Advanced Disease

Medicare does not cover long-term nursing home care or assisted living facilities, though it will pay for up to 100 days of skilled nursing or rehabilitation immediately following a hospital stay of three or more days.

For prostate cancer patients with advanced disease who may eventually need assistance with daily activities, this represents a critical planning consideration. Medicare also does not cover:

• Personal home care assistance (bathing, dressing, transferring) unless the patient is homebound and receiving skilled nursing care
• Housekeeping services (shopping, meal preparation, cleaning) except during hospice care

Patients and families should plan for potential long-term care costs through private long-term care insurance, personal savings, or Medicaid planning. Long-term care insurance premiums can be paid from Health Savings Account funds if purchased before Medicare enrollment.

Alternative and Complementary Therapies

Medicare does not cover most alternative medicine approaches, with limited exceptions:

• Acupuncture for chronic low-back pain is covered
• Chiropractic services for vertebral subluxation are covered

Many prostate cancer patients explore complementary approaches for symptom management, pain control, or quality of life, including acupuncture for other indications, massage therapy, meditation programs, and nutritional supplements. These costs are generally out-of-pocket expenses.

Cosmetic Procedures and Routine Foot Care

Most cosmetic procedures are not covered, though Medicare will cover reconstructive surgery related to injury, illness, or deformity with prior authorization.

Routine foot care (corn and callus removal, routine toenail trimming) is not covered except when medically necessary for conditions like diabetes-related foot problems. This can be relevant for prostate cancer patients with diabetes or peripheral neuropathy from chemotherapy.

International Travel

Medicare does not cover healthcare services outside the United States except in very limited circumstances (such as on cruise ships within six hours of a U.S. port). Patients traveling abroad should consider supplemental travel health insurance.

Medicare Advantage Plans: Understanding the Trade-Offs for Cancer Patients

The Appeal and the Concerns

While Medicare Advantage (Part C) plans offer attractive benefits like dental, vision, and hearing coverage that original Medicare doesn't provide, prostate cancer patients should carefully weigh these advantages against potentially serious limitations that have been documented in recent peer-reviewed research.

Network Restrictions Can Limit Access to High-Quality Cancer Care

Recent research published in multiple peer-reviewed journals has documented concerning patterns for cancer patients enrolled in Medicare Advantage:

Reduced Access to Top-Ranked Hospitals: A 2024 study published in the American Journal of Managed Care analyzed Medicare patients who underwent complex cancer surgeries between 2015 and 2017, including procedures commonly performed for cancer treatment. The research found that Medicare Advantage enrollees were 6.0 percentage points less likely to receive treatment at top-ranked hospitals compared to traditional Medicare patients. For Medicare Advantage plans without out-of-network benefits, this gap widened to 7.5 percentage points.

Lower Volume Centers and Mortality Concerns: Research published in the Journal of Clinical Oncology (2022) demonstrated that Medicare Advantage enrollees were less likely to undergo cancer surgery at high-volume hospitals—where surgical volume correlates with quality of care and better outcomes—and experienced increased 30-day mortality rates after stomach, pancreatic, and liver cancer surgery compared to traditional Medicare patients.

Radiation Therapy Limitations: A 2025 Harvard T.H. Chan School of Public Health study examining 31,563 radiation treatment episodes found that Medicare Advantage's prior authorization requirements and network limitations may affect radiation treatment options for cancer patients. The study noted that these restrictions have "prompted concerns about possible delays and denials in necessary radiotherapy treatments."

Restricted Provider Networks: An analysis published in Oncology News Central (November 2025) noted that "cancer patients with Medicare Advantage insurance see a more restricted network of providers than those who have traditional Medicare." This can be particularly problematic when patients want to access specialized cancer centers like MD Anderson, Memorial Sloan Kettering, Mayo Clinic, UCSF Medical Center, or other National Cancer Institute-designated comprehensive cancer centers that may not be in-network.

Prior Authorization and Utilization Management

Medicare Advantage plans commonly employ strategies not used in traditional Medicare:

• Prior authorization requirements: Pre-approval needed for expensive cancer treatments, potentially causing delays
• Step therapy protocols: Requirements to try cheaper medications first before accessing more expensive options, even when the more expensive drug may be more appropriate
• Quantity limits: Restrictions on medication supplies
• Network adequacy concerns: Limited networks may make it difficult to find specialists, particularly in rural areas

A 2025 commentary in JAMA Network Open noted that while utilization management tools may reduce low-value care, "critical questions remain about whether Medicare Advantage vs traditional Medicare beneficiaries experience differences in cancer diagnosis; access to high-quality oncologists, organizations, and clinical trials; and initiation of guideline-recommended treatments."

Out-of-Pocket Maximums: Protection with Important Caveats

Medicare Advantage plans cap annual out-of-pocket spending at $9,250 for in-network care in 2026 (some plans have lower limits), which can provide important financial protection. However:

• You must use in-network providers to benefit from this cap
• Out-of-network costs can be significantly higher or even unlimited
• You may pay up to 20% coinsurance for radiation and chemotherapy until reaching the maximum
• Specialist copays (often $50 or more per visit) accumulate quickly with frequent oncology appointments
• Hospital admissions under Medicare Advantage often cost more than under traditional Medicare with Medigap

Example: A prostate cancer patient receiving radiation therapy might pay 20% coinsurance for each treatment session plus $50 specialist copays for twice-monthly oncologist visits, with costs accumulating until reaching the $9,250 out-of-pocket maximum.

The Complete Trade-Off Analysis

Medicare Advantage Advantages:

• Lower monthly premiums (often $0-50/month)
• Dental, vision, hearing coverage included
• Out-of-pocket maximum protection (in-network only)
• Integrated prescription drug coverage (most plans)
• Extra benefits like gym memberships, OTC allowances ($45-75/month typical)
• Simplified billing (one plan instead of multiple)

Medicare Advantage Disadvantages:

• Restricted to network providers
• May limit access to specialized cancer centers and top-ranked hospitals
• Prior authorization can delay treatment
• Step therapy requirements may force trying less optimal medications first
• Limited or no coverage for out-of-network care
• Cannot purchase Medigap supplement insurance once enrolled in Medicare Advantage (in most states)
• Provider networks can change annually
• May face higher costs for complex cancer care despite out-of-pocket maximum

Original Medicare + Medigap: The Alternative Approach

Advantages:

• Access to any Medicare-accepting provider nationwide
• No network restrictions
• No prior authorization requirements
• Freedom to seek care at any specialized cancer center
• Easier access to clinical trials at major research institutions
• Medigap Plan G covers most Part A and Part B cost-sharing
• More predictable costs
• Provider relationships don't change year to year

Disadvantages:

• Higher monthly premiums (Part B $202.90 + Medigap $150-300 + Part D $30-100)
• No dental, vision, or hearing coverage (unless purchased separately)
• Medigap may be unavailable or expensive for those with pre-existing conditions (depending on state and enrollment timing)
• Must coordinate three separate plans (Part B, Medigap, Part D)
• No out-of-pocket maximum (though Medigap Plan G covers most costs)

Making the Choice

For prostate cancer patients, the decision between Medicare Advantage and original Medicare with Medigap depends on individual priorities:

Consider Medicare Advantage if:

• You're comfortable with network restrictions
• Your preferred oncologist and hospital are in-network
• You have stable, less complex disease
• Monthly premium savings are critical
• You value dental/vision/hearing coverage
• You're willing to navigate prior authorization processes

Consider Original Medicare + Medigap if:

• You want access to any specialized cancer center
• You're participating in clinical trials
• You have complex disease requiring subspecialist care
• You travel frequently or live in multiple locations
• You want to avoid prior authorization delays
• You prefer predictable costs and fewer administrative hassles
• You can afford higher monthly premiums

Critical Timing Note: You have a one-time opportunity to purchase Medigap without medical underwriting during the six-month period starting when you're both 65 or older and enrolled in Medicare Part B. After this window, insurance companies in most states can deny coverage or charge higher premiums based on health conditions. Once you choose Medicare Advantage, switching to Medigap later may be difficult or impossible.

CRITICAL: Planning Before Medicare Enrollment - Don't Miss These Opportunities

Why This Matters for Prostate Cancer Patients

Most men enroll in Medicare at age 65, but the decisions you make in the years leading up to that enrollment can significantly impact your financial preparedness for healthcare costs during retirement—especially if you're later diagnosed with prostate cancer or already managing the disease. Once you enroll in Medicare, certain tax-advantaged opportunities close permanently. Smart planning in your late 50s and early 60s can create a substantial healthcare fund to cover Medicare's many gaps.

The Critical HSA Window: Before Medicare Enrollment

The Opportunity You Cannot Miss

If you're still employed and covered by a high-deductible health plan (HDHP) before age 65, establishing and maximally funding a Health Savings Account (HSA) is one of the most powerful financial moves you can make for future healthcare costs. This opportunity disappears completely the moment you enroll in Medicare.

Why HSAs Are So Valuable

Health Savings Accounts offer a triple tax advantage that no other account provides:

1. Tax deduction on contributions - Reduces your current taxable income
2. Tax-free growth - Investment earnings accumulate without taxation
3. Tax-free withdrawals - No taxes on withdrawals for qualified medical expenses, ever

For someone in the 24% federal tax bracket, this translates to saving approximately 30-35% (including FICA and potential state taxes) on every dollar contributed and used for medical expenses.

The Hard Deadline: Medicare Enrollment

Once you enroll in any part of Medicare (A, B, C, or D), you immediately and permanently lose the ability to make HSA contributions, even if you:

• Continue working full-time
• Still have an HSA-eligible health plan through your employer
• Have significant income from employment, pensions, or investments
• Are only 65 years old with decades of healthcare expenses ahead

The contribution door slams shut at Medicare enrollment, regardless of your circumstances.

Strategic HSA Planning Timeline

Ages 55-64: The Critical Accumulation Years

If you're employed with access to an HSA-eligible high-deductible health plan:

Immediate Actions:

1. Enroll in the HDHP and open an HSA - Don't delay. Every year counts.

2. Contribute the maximum allowed (2026 limits):

   • Self-only coverage: $4,400
   • Family coverage: $8,750
   • Age 55+ catch-up: Additional $1,000

3. Have your spouse contribute too - If your spouse is also 55+ and HSA-eligible, they can contribute the catch-up amount to their own separate HSA

Example of 10-Year Accumulation:

A 55-year-old contributing the maximum with catch-up ($5,400/year in 2026) for 10 years before Medicare enrollment at 65:

• Base contributions: $54,000
• With 6% average annual return: $71,400+
• All available tax-free for medical expenses in retirement

For a couple both contributing: potentially $140,000+ in tax-free healthcare funds.

Advanced Strategy: Pay Out-of-Pocket Now, Invest HSA Funds

If you can afford it:

• Pay current medical expenses from regular income
• Let HSA contributions remain invested
• Maximize compound growth over the decade
• Save receipts - You can reimburse yourself tax-free decades later for expenses paid out-of-pocket

This strategy treats the HSA as a dedicated retirement healthcare investment account.

The Medicare Part A Retroactive Trap

A Critical Pitfall That Catches Many People

This is one of the most dangerous and poorly understood aspects of Medicare enrollment:

The Problem:

When you apply for Social Security benefits, you are automatically enrolled in Medicare Part A. That enrollment can be retroactive up to 6 months before your application date.

Why This Matters:

Any HSA contributions made during the retroactive Medicare coverage period become excess contributions subject to:

• 6% excise tax per year the excess remains in the account
• Potential income tax on the excess amount
• Penalties that compound if not corrected

Real-World Example:

John turns 65 in January 2026. He continues working with employer health insurance and maximally funds his HSA through June 2026 ($2,700 contributed). In July 2026, he applies for Social Security retirement benefits.

Problem: Medicare Part A is retroactive to January 2026 (6 months back). All $2,700 in HSA contributions from January-June are now excess contributions subject to penalties.

The Safe Approach:

Stop HSA contributions 6 months before applying for Social Security or Medicare, even if you're still working and still covered by an HSA-eligible plan.

If you plan to retire and start Social Security at 65:

• Make your last HSA contribution at age 64½
• This provides a 6-month buffer against retroactive coverage

Delaying Medicare to Extend HSA Eligibility

When You Can Delay Medicare

If you're still actively employed at age 65 and covered by an employer group health plan:

The Rules:

• Employer must have 20 or more employees
• Coverage must be through your current active employment (or your spouse's)
• You are the employee or spouse of the employee (not COBRA, not retiree coverage)

The Benefits:

• Delay Medicare Part B enrollment without penalty
• Continue HSA contributions past age 65
• Build larger HSA balance
• Special Enrollment Period when employment/coverage ends (8 months to enroll)

Critical Coordination:

If delaying Medicare:

1. Do NOT apply for Social Security - This triggers automatic Medicare Part A enrollment
2. Get written confirmation from your employer's HR that coverage is creditable and you can delay
3. Keep documentation proving continuous creditable coverage
4. Enroll within 8 months of employment/coverage ending to avoid penalties

Example Strategy:

Sarah works until age 68 with employer coverage (large company with 500+ employees). She:

• Delays Social Security and Medicare enrollment
• Continues maximum HSA contributions ($5,400/year) from 65-68
• Accumulates additional $16,200+ in contributions plus growth
• Enrolls in Medicare at 68 using Special Enrollment Period (no penalty)

What to Do in the Final Year Before Medicare

Six Months Before Enrollment:

1. Stop all HSA contributions - Protect against retroactive Medicare coverage
2. Maximize final contribution - Contribute as much as possible before the 6-month cutoff
3. Verify contribution limits - If enrolling mid-year, contributions are pro-rated
4. Review investment allocation - Consider moving some HSA funds to cash for near-term medical expenses

Three Months Before Enrollment:

1. Decide on Medicare plan strategy - Medicare Advantage vs. Original Medicare + Medigap
2. Research Medigap availability - Check if you can purchase without medical underwriting in your state
3. Review prescription drug plans - Compare Part D formularies for your medications
4. Calculate first-year costs - Estimate premiums, deductibles, and out-of-pocket expenses
5. Plan HSA usage strategy - Determine which Medicare costs you'll pay from HSA vs. other sources

At Enrollment:

1. Confirm HSA contribution cutoff - No contributions after Medicare effective date
2. Update payroll - Stop HSA payroll deductions immediately
3. Notify HSA administrator - Inform them of Medicare enrollment
4. Plan HSA withdrawals - Set up system to use HSA for Medicare premiums and qualified expenses

Additional Pre-Medicare Financial Moves

Consider Long-Term Care Insurance (Ages 50-65)

Long-term care insurance becomes much more expensive after 65 and may be unavailable if you have significant health issues. Premiums can be paid from HSA funds if purchased before Medicare enrollment.

Key considerations:

• Evaluate policies in your late 50s or early 60s
• Premiums are significantly lower when purchased younger
• HSA funds can pay premiums (age-based limits apply)
• Medicare does not cover long-term custodial care
• Critical for prostate cancer patients who may face advanced disease

Maximize Medigap Enrollment Window

You have a one-time, six-month Medigap Open Enrollment Period starting when you're both 65+ and enrolled in Medicare Part B. During this window:

• Insurance companies cannot deny coverage due to health conditions
• Cannot charge higher premiums based on health status
• Cannot impose waiting periods for pre-existing conditions

After this window closes, in most states you may be unable to purchase Medigap or face much higher premiums if you have health issues like cancer.

If diagnosed with prostate cancer after age 60 but before Medicare:

• Enroll in Medigap during your guaranteed-issue period
• Don't delay or you may be unable to get coverage later
• Medigap Plan G typically provides the most comprehensive coverage

Review Employer Retiree Benefits

Before leaving employment:

• Understand what retiree health benefits are available
• Determine if retiree coverage coordinates with Medicare
• Check if benefits include prescription drug coverage creditable for Part D
• Verify COBRA availability and duration
• Document all coverage for creditable coverage proof

Common Mistakes to Avoid

DON'T:

1. Assume you can restart HSA contributions later - Once on Medicare, this door is permanently closed

2. Apply for Social Security without considering HSA impact - The automatic Medicare Part A enrollment and retroactive coverage will end HSA eligibility

3. Forget about the 6-month buffer - Stop HSA contributions 6 months before Medicare/Social Security application

4. Miss your Medigap enrollment window - You may never get another chance at guaranteed-issue coverage

5. Delay enrollment thinking you'll save money - Late enrollment penalties for Part B and Part D are permanent and compound over time

6. Assume employer coverage at a small company (under 20 employees) exempts you from Medicare - Medicare becomes primary, you must enroll in Part B

7. Overlook spousal considerations - Coordinate both spouses' Medicare enrollment and HSA strategies

Special Considerations for Prostate Cancer Patients

If Diagnosed Before Medicare Eligibility:

1. Accelerate HSA funding - You now know you'll have significant future medical expenses
2. Evaluate employment decisions carefully - Continuing to work for HSA access may be valuable
3. Consider disability status - If eligible for Social Security Disability, you'll be automatically enrolled in Medicare after 24 months (ends HSA eligibility)
4. Plan for treatment costs - HSA can cover deductibles, coinsurance, clinical trial expenses
5. Secure Medigap during open enrollment - Critical for ongoing cancer care without network restrictions

If High Risk Due to Family History:

Even without diagnosis, men with strong family history of prostate cancer should:

• Maximize HSA contributions
• Plan for potential future cancer-related expenses
• Ensure Medigap enrollment during guaranteed-issue window
• Build healthcare fund before retirement

The Bottom Line: Act Before Age 65

The years between ages 55 and 65 represent your final opportunity to:

• Establish and fund an HSA
• Build a substantial tax-advantaged healthcare fund
• Prepare financially for Medicare's coverage gaps
• Secure Medigap coverage without medical underwriting

For men who may face prostate cancer diagnosis or already have the disease, these pre-Medicare years are critical for financial preparation. The decisions you make—or fail to make—during this window can mean the difference between tens of thousands of dollars in out-of-pocket costs versus having those expenses covered by tax-free HSA funds.

Don't wait until you're 64½ to think about this. Start planning now.

Action Checklist for Men Ages 55-64

Immediate (Do This Now):

• [ ] Check if your employer offers an HSA-eligible high-deductible health plan
• [ ] Enroll in HDHP during next open enrollment if available
• [ ] Open an HSA if you don't have one
• [ ] Set up automatic maximum contributions
• [ ] If age 55+, ensure catch-up contribution is included
• [ ] Review HSA investment options and allocate funds appropriately

Annually (Every Year Until Medicare):

• [ ] Maximize HSA contributions
• [ ] Review and adjust HSA investments
• [ ] Save receipts for all medical expenses (can reimburse from HSA later)
• [ ] Calculate projected HSA balance at age 65

Age 64 (Critical Planning Year):

• [ ] Decide on Medicare enrollment strategy (at 65 or delay if still working)
• [ ] If enrolling at 65: Stop HSA contributions 6 months before
• [ ] Research Medigap plans available in your state
• [ ] Compare Medicare Advantage vs. Original Medicare for your situation
• [ ] Review Part D prescription drug plan options

Six Months Before Medicare Enrollment:

• [ ] Make final HSA contributions
• [ ] Stop all future HSA contributions
• [ ] Stop payroll deductions
• [ ] Plan HSA withdrawal strategy for Medicare costs

At Medicare Enrollment:

• [ ] Enroll in Medicare Part B during enrollment window
• [ ] Enroll in Medigap during guaranteed-issue period (if choosing this option)
• [ ] Enroll in Part D prescription drug plan
• [ ] Set up HSA withdrawals for Medicare premiums and medical expenses
• [ ] Confirm with HSA administrator that contributions have ceased

This pre-Medicare planning can make the difference between struggling with healthcare costs in retirement and having a robust, tax-advantaged fund to cover Medicare's many gaps—particularly critical for prostate cancer patients who face ongoing treatment costs, side effect management, and quality-of-life expenses throughout their lives.

Health Savings Accounts: A Critical Tool for Managing Uncovered Expenses

The Power of Pre-Medicare HSA Accumulation

Many prostate cancer patients don't realize they can continue to use Health Savings Account (HSA) funds accumulated before Medicare enrollment to pay for qualified medical expenses tax-free, even after enrolling in Medicare. This is particularly valuable for covering the many expenses Medicare doesn't pay.

The Medicare-HSA Rule: What You Need to Know

Cannot Make New Contributions: Once enrolled in any part of Medicare (A, B, C, or D), you can no longer make new HSA contributions, even if you're still covered by a high-deductible health plan.

Can Still Use Existing Funds: All money previously saved in your HSA remains available tax-free for qualified medical expenses throughout your lifetime.

Medicare Premiums Are Qualified Expenses: You can use HSA funds to pay Medicare Part B premiums, Part D premiums, and Medicare Advantage premiums (but NOT Medigap supplemental insurance premiums).

Using HSA Funds for Uncovered Medicare Expenses

Your HSA can pay tax-free for numerous expenses Medicare doesn't cover:

Insurance Premiums:

• Medicare Part B monthly premiums ($202.90 for most in 2026)
• Medicare Part D prescription drug premiums
• Medicare Advantage premiums
• Long-term care insurance premiums (age-based limits apply)
• NOT Medigap premiums (these are not HSA-eligible)

Medical Expenses Medicare Doesn't Cover:

• Adult incontinence supplies (critical for prostate cancer patients)
• Dental care, cleanings, fillings, crowns, dentures
• Vision care: glasses, contact lenses, eye exams, LASIK
• Hearing aids and hearing exams (both OTC and prescription)
• Over-the-counter medications
• Acupuncture and chiropractic care (beyond Medicare's limited coverage)
• Medical equipment and supplies
• Home modifications for medical necessity
• Transportation costs for medical care

Medicare Cost-Sharing:

• Part A and Part B deductibles
• Copayments and coinsurance
• Prescription drug costs and Part D deductible

For Prostate Cancer Patients Specifically

HSAs can cover common prostate cancer-related out-of-pocket expenses:

• Incontinence supplies and related products ($600-$2,400/year)
• Erectile dysfunction treatments not fully covered by Medicare
• Nutritional supplements recommended for bone health during ADT
• Alternative therapies for side effect management (acupuncture, massage)
• Transportation to medical appointments and clinical trials
• Lodging expenses when receiving treatment at distant facilities
• Home care assistance not covered by Medicare
• Premium costs for supplemental insurance
• Medical foods and special dietary needs
• Exercise programs for maintaining strength during treatment

Important HSA Distinctions from FSAs

HSAs vs. FSAs - Critical Differences:

Many people confuse Health Savings Accounts (HSAs) with Flexible Spending Accounts (FSAs). Understanding the difference is crucial:

HSAs (Health Savings Accounts):

• Funds roll over year after year - never expire
• No "use it or lose it" rule
• You own the account - it's portable if you change jobs
• Available only with high-deductible health plans
• Can be invested for growth
• Triple tax advantage (deductible, tax-free growth, tax-free withdrawals)

FSAs (Flexible Spending Accounts):

• Generally "use it or lose it" at year end
• Employer owns the account - not portable
• Some plans allow small carryover ($680 for 2026) or 2.5-month grace period
• Available with various health plans
• Cannot be invested
• Lose access if you leave your job

This distinction matters: HSA funds you accumulate before Medicare become a permanent healthcare fund for life. FSA funds typically must be spent within the plan year or a short grace period.

Important Cautions

Keep Excellent Records: Save all receipts for HSA-funded medical expenses. The IRS may require documentation that withdrawals were used for qualified expenses.

Spousal Coordination: If your spouse is also 55+, they can make catch-up contributions to their own separate HSA (the catch-up contribution cannot be split or shared).

State Taxes: While HSA contributions are federally tax-deductible, a few states (California, New Jersey) don't recognize HSA tax benefits for state income tax purposes.

The Bottom Line on HSAs

For prostate cancer patients, HSA funds accumulated during working years represent a valuable, tax-advantaged resource to cover Medicare's extensive coverage gaps. If you have the opportunity to contribute to an HSA before Medicare enrollment, maximize those contributions. If you already have HSA funds, remember they remain available throughout retirement to pay for the many expenses—from incontinence supplies to hearing aids to long-term care—that Medicare won't cover.

Key Takeaway: Unlike flexible spending accounts (FSAs) with their "use it or lose it" rules, HSA funds never expire and remain yours forever. This makes HSAs one of the best financial tools available for managing healthcare costs in retirement, particularly for those facing the extensive out-of-pocket expenses associated with cancer treatment and its long-term effects.

Additional Strategies for Bridging Coverage Gaps

Medicare Savings Programs and Financial Assistance

Extra Help (Low-Income Subsidy): Medicare beneficiaries with limited income and resources may qualify for Extra Help, which pays for most Part D costs including premiums, deductibles, and copayments. In 2026, individuals with income up to approximately $23,000 and couples up to $31,000 may qualify.

Medicare Savings Programs: State programs that help pay Medicare premiums and sometimes deductibles and coinsurance for those with limited income. Four programs exist with varying income limits.

Medicaid: For those meeting income and asset requirements, Medicaid can help cover Medicare premiums and provide additional benefits like dental care and long-term care.

State Pharmaceutical Assistance Programs (SPAPs): Some states offer programs to help with prescription drug costs. Examples include EPIC in New York and PACE in Pennsylvania.

Patient Assistance Programs

Pharmaceutical Manufacturer Programs: Most companies making expensive cancer drugs offer patient assistance programs with free or reduced-cost medications based on income.

Co-Pay Assistance Foundations:

• Patient Access Network (PAN) Foundation
• CancerCare Co-Payment Assistance Foundation
• Good Days (formerly Chronic Disease Fund)
• Patient Advocate Foundation
• HealthWell Foundation

Cancer-Specific Resources:

• American Cancer Society: Transportation assistance, lodging programs
• Cancer Support Community: Free support services
• National Cancer Institute: Clinical trial matching (trials often cover treatment costs)

Veterans Benefits

Veterans may be eligible for VA healthcare benefits that can supplement Medicare, potentially covering services Medicare doesn't. Contact your local VA Medical Center to explore eligibility.

The Importance of Annual Review and Planning

Open Enrollment Period (October 15 - December 7)

The Centers for Medicare & Medicaid Services recommends that all beneficiaries review their coverage annually during the Open Enrollment Period because:

• Medicare Advantage plan networks, formularies, and benefits change each year
• Your health needs and medications may have changed
• New plans may offer better coverage for your current situation
• Part D formularies are updated annually
• Premium costs change

Medicare Advantage Open Enrollment (January 1 - March 31)

Existing Medicare Advantage enrollees can make one plan change during this period, either to a different Medicare Advantage plan or back to Original Medicare.

Planning Ahead for Cancer Diagnosis

Before Treatment Begins:

1. Verify Coverage: Confirm that your oncologists, hospital, radiation facility, and preferred treatment centers are in-network (if on Medicare Advantage)

2. Review Formularies: Check that your Medicare Part D or Medicare Advantage plan covers the medications you might need

3. Calculate Potential Costs: Understand your maximum out-of-pocket exposure for the year

4. Consider Switching Plans: If your current plan doesn't adequately cover your needs, evaluate switching during Open Enrollment

5. Assess Supplemental Coverage: Determine if you need Medigap, dental insurance, or other supplemental policies

6. Identify Financial Resources: Research patient assistance programs, co-pay foundations, and other support before costs accumulate

Resources for Personalized Guidance

State Health Insurance Assistance Programs (SHIP): Free, unbiased Medicare counseling available in every state. SHIP counselors can help compare plans, understand coverage, and navigate enrollment.

Medicare.gov: Official website with plan comparison tools, coverage information, and cost calculators

1-800-MEDICARE (1-800-633-4227): Official Medicare helpline, available 24/7 (TTY: 1-877-486-2048)

Cancer-Specific Resources:

• National Cancer Institute: 1-800-4-CANCER (1-800-422-6237)
• CancerCare: 1-800-813-HOPE (1-800-813-4673)
• Patient Advocate Foundation: 1-800-532-5274

Conclusion

While Medicare provides essential coverage for prostate cancer diagnosis and treatment, significant gaps exist that can create financial hardship for patients managing the disease and its side effects. Understanding these limitations and planning accordingly allows patients to:

• Budget appropriately for predictable out-of-pocket costs
• Make informed decisions between Medicare Advantage and Original Medicare with Medigap
• Maximize the value of Health Savings Account funds accumulated before Medicare enrollment
• Explore financial assistance options proactively
• Plan for potential long-term care needs
• Avoid financial surprises during an already challenging time
• Focus on what matters most: health and quality of life

For cancer patients specifically, the choice between Medicare Advantage and Original Medicare with Medigap supplements is not merely about cost—it's about ensuring access to the highest quality care, specialized cancer centers, clinical trials, and the medical teams best equipped to manage complex disease. Recent research documenting reduced access to top-ranked hospitals and high-volume centers for Medicare Advantage enrollees undergoing cancer treatment should weigh heavily in this decision.

The coverage gaps in Medicare—from incontinence supplies to hearing aids to long-term care—are substantial, but they can be anticipated and managed through careful planning, appropriate use of HSA funds for those who have them, and enrollment in supplemental coverage that matches your individual needs and priorities.

Most importantly, the years between ages 55 and 65 represent a critical window for financial preparation. Establishing and maximally funding an HSA during this period, securing Medigap coverage during the guaranteed-issue enrollment window, and understanding Medicare's limitations before you need the coverage can make the difference between financial stress and financial security during cancer treatment and recovery.

Patients are strongly encouraged to:

• Begin HSA planning in your 50s - Don't wait until you're approaching Medicare eligibility
• Discuss coverage questions with their healthcare providers
• Contact Medicare directly at 1-800-MEDICARE (1-800-633-4227)
• Visit medicare.gov/coverage to research specific services
• Consult with a State Health Insurance Assistance Program (SHIP) counselor for personalized, unbiased guidance
• Review coverage annually during the Open Enrollment Period
• Consider their long-term healthcare needs, not just current costs, when making coverage decisions
• Stop HSA contributions 6 months before Medicare enrollment to avoid penalties

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Verified Sources and Citations

1. The American Legion - "What Medicare will not cover in 2026" - Savvy Living column by Jim Miller
   https://www.legion.org

2. Centers for Medicare & Medicaid Services - "Medicare & You 2026" - Official Medicare handbook
   https://www.medicare.gov/medicare-and-you

3. Centers for Medicare & Medicaid Services - "What Medicare Covers"
   https://www.medicare.gov/what-medicare-covers

4. Centers for Medicare & Medicaid Services - "2026 Medicare Parts A & B Premiums and Deductibles" - Official announcement
   https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-and-deductibles

5. National Cancer Institute - "Prostate Cancer Treatment (PDQ®)–Patient Version"
   https://www.cancer.gov/types/prostate/patient/prostate-treatment-pdq

6. American Cancer Society - "Treatment Side Effects: Urinary and Bladder Problems"
   https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/urinary-bladder-problems.html

7. U.S. Congress - "Inflation Reduction Act of 2022" - Public Law 117-169, Medicare Part D provisions
   https://www.congress.gov/bill/117th-congress/house-bill/5376

8. Medicare.gov - "Part D Out-of-Pocket Costs"
   https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/costs-in-the-coverage-gap

9. State Health Insurance Assistance Program (SHIP) - National Directory
   https://www.shiphelp.org

10. Patient Access Network Foundation - "Co-Pay Relief for Prostate Cancer"
    https://www.panfoundation.org

11. U.S. News & World Report - "Medicare and Hearing Aids: Your Guide to Coverage & Costs in 2026"
    https://health.usnews.com/medicare/articles/does-medicare-cover-hearing-aids

12. MedicareResources.org - "Does Medicare cover hearing aids?" - December 2025
    https://www.medicareresources.org/faqs/does-medicare-cover-hearing-aids/

13. Hearing Loss Association of America - "Medicare Hearing Aid Coverage Act"
    https://www.hearingloss.org/advocacy-and-resources/action-alerts/medicare-hearing-aid-coverage-act/

14. U.S. Congress - "H.R.500 - Medicare Hearing Aid Coverage Act of 2025" - 119th Congress
    https://www.congress.gov/bill/119th-congress/house-bill/500/text

15. The Senior List - "Medicare Coverage of Hearing Aids in 2026"
    https://www.theseniorlist.com/hearing-aids/medicare/

16. AARP - "3 Prescription Drug Changes Coming to Medicare in 2026" - December 24, 2025
    https://www.aarp.org/medicare/future-medicare-drug-payment-changes-2026/

17. Medicare.gov - "How much does Medicare drug coverage cost?"
    https://www.medicare.gov/health-drug-plans/part-d/basics/costs

18. Kim DH, et al. - "Surgery at High-Ranked Hospitals and Patient Outcomes in Medicare Advantage vs Traditional Medicare" - American Journal of Managed Care, 2024
    https://www.ajmc.com/view/surgery-at-high-ranked-hospitals-and-patient-outcomes-in-medicare-advantage-vs-traditional-medicare

19. Raoof M, et al. - "Impact of Medicare Advantage Enrollment on Treatment and Outcomes of Older Patients With Cancer" - Journal of Clinical Oncology, 2022
    https://ascopubs.org/doi/10.1200/JCO.21.02054

20. Lam MB, et al. - "Radiotherapy Utilization in Traditional Medicare and Medicare Advantage" - Harvard T.H. Chan School of Public Health, April 2025
    https://hsph.harvard.edu/news/medicare-advantage-may-limit-radiation-treatment-options-for-cancer-increase-cost-and-duration-of-care/

21. Mitchell AP, Kyle MA - "The Promise and Perils of Oncology Care in Medicare Advantage" - JAMA Network Open, 2025
    https://pmc.ncbi.nlm.nih.gov/articles/PMC12120503/

22. Kalidindi S, et al. - "Use of Low-Value Cancer Treatments in Medicare Advantage Versus Traditional Medicare" - Journal of Clinical Oncology, 2024
    https://ascopubs.org/doi/10.1200/JCO-24-01907

23. Oncology News Central - "Lower-Quality Cancer Care for Medicare Advantage Enrollees? Study Shows Concerning Gaps" - November 2025
    https://www.oncologynewscentral.com/oncology/lower-quality-cancer-care-for-medicare-advantage-enrollees-study-shows-concerning-gaps

24. Managed Healthcare Executive - "Is Medicare Advantage a Disadvantage For Patients With Cancer?" - January 2026
    https://www.managedhealthcareexecutive.com/view/is-medicare-advantage-a-disadvantage-for-patients-with-cancer-

25. ValuePenguin - "What Are the Best Medicare Plans for Cancer Patients?"
    https://www.valuepenguin.com/best-medicare-plans-cancer

26. Boomer Benefits - "Does Medicare Cover Cancer Treatment (And Meds)" - November 2025
    https://boomerbenefits.com/medicares-coverage-for-cancer/

27. Humana - "Does Medicare Cover Cancer Treatment?"
    https://www.humana.com/medicare/medicare-resources/does-medicare-cover-cancer-treatment

28. AARP - "What Changes Are Coming to Medicare in 2026?"
    https://www.aarp.org/medicare/whats-new-in-medicare-2026/

29. The Motley Fool - "Medicare Advantage Can No Longer Cover These Items in 2026" - January 2026
    https://www.fool.com/retirement/2026/01/04/medicare-advantage-no-longer-cover-items-2026/

30. Fidelity - "HSA contribution limits and eligibility rules for 2025 and 2026" - August 2025
    https://www.fidelity.com/learning-center/smart-money/hsa-contribution-limits

31. MedicareResources.org - "Can I enroll in Medicare if I have an HSA?" - November 2025
    https://www.medicareresources.org/faqs/can-i-enroll-in-medicare-if-i-have-an-hsa/

32. Centers for Medicare & Medicaid Services - "What's a Health Savings Account?" - CMS Product No. 11951, October 2025
    https://www.cms.gov/marketplace/outreach-and-education/health-savings-account.pdf

33. HealthEquity - "Key changes to HSAs and (potentially) HRAs in 2026 and beyond" - December 2025
    https://blog.healthequity.com/key-changes-to-hsas-and-hras-in-2026-and-beyond

34. Risk Strategies - "Medicare & HSA Contributions: A Guide for Employers and Near-Retirees" - 2026
    https://www.risk-strategies.com/blog/medicare-hsa-contributions-a-guide-for-employers-and-near-retirees

35. Lively - "2026 HSA Eligibility, Coverage, and OBBB Changes"
    https://livelyme.com/guides/obbb-hsa-guide

36. MedicareResources.org - "Do I have to stop HSA contributions before my Medicare coverage starts?" - November 2025
    https://www.medicareresources.org/faqs/do-i-have-to-stop-hsa-contributions-before-my-medicare-coverage-starts/

37. Internal Revenue Service - "Publication 969 (2024), Health Savings Accounts and Other Tax-Favored Health Plans"
    https://www.irs.gov/publications/p969

38. Internal Revenue Service - "Notice 2026-05: HSA Guidance Under One Big Beautiful Bill Act" - December 2025
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39. HealthCare.gov - "New in 2026: More plans now work with Health Savings Accounts"
    https://www.healthcare.gov/hsa-options/

40. HealthEquity - "As you approach Medicare eligibility at age 65, please be aware of some important rules regarding Medicare and your health savings account (HSA)"
    https://www.healthequity.com/doclib/hsa/medicare.pdf

41. Devoted Health - "2026 Prior Authorization List for Medicare Part B Drugs"
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42. AbbVie - "LUPRON DEPOT® (leuprolide acetate for depot suspension)"
    https://www.lupronprostatecancer.com/hcp/commitment

43. Urology Times - "Leuprolide tops urology spending for Medicare Part B drugs" - February 2026
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44. Aetna - "HSA vs. FSA vs. HRA: What is the Difference Between Them?"
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45. HealthInsurance.org - "What is the difference between an FSA and an HSA?" - November 2025
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46. FINRA - "Six Things to Know About HSAs"
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Disclaimer: This article is intended for educational purposes only and should not be considered medical, legal, or financial advice. Medicare coverage policies, costs, and regulations are subject to change. Patients should consult with their healthcare providers, Medicare counselors (SHIP), and financial advisors regarding their individual situations. Always verify current information at medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227). The research cited regarding Medicare Advantage and cancer care outcomes represents peer-reviewed studies but individual experiences may vary. Each patient's situation is unique and coverage decisions should be based on individual health needs, financial circumstances, and personal priorities.