The odds are that someone in your life has already been diagnosed with prostate cancer. One of the most common cancers, prostate cancer will affect one in seven or eight American men, usually later in life, according to the Centers for Disease Control.
The good news is that survival rates are high—nearly 100 percent—when prostate cancer is treated before it spreads to other parts of the body, according to the American Cancer Society. That’s why it’s important to get regular prostate cancer screenings, including prostate-specific antigen (PSA) tests, when you’re in the target age group, which the CDC defines as 55 to 69 years old. Of course, you may be wondering whether Medicare pays for the PSA test. Fortunately, the answer is yes, it does.
Furthermore, if your screening reveals cancer, Medicare covers prostate surgery and other treatment just as it covers costs for treating other cancers. Let’s look at the ins and outs of coverage for this important health issue.
What Prostate Cancer-Screening Services Are Covered?
After you turn 50, Medicare Part B will cover preventive prostate cancer screening. That means that once a year, Medicare Part B covers a PSA test and a digital rectal exam (DRE).
Medicare may also cover diagnostic prostate cancer screenings if they’re needed. What’s the difference between preventive and diagnostic screening? Preventive screenings are the ones you get when you’re symptom-free. But if you go to the doctor reporting symptoms or changes in your body, you might get a diagnostic screening to check those out.
How Much Does Medicare Pay for?
If you’re over 50 and visit a participating provider who accepts assignments, you will pay nothing for your annual PSA test. Medicare Part B will cover 100 percent of the approved amount, with no copay or deductible. This is also true with Medicare Advantage plans, as long as your provider is in-network.
If you visit a doctor who doesn’t accept assignments, you may be charged a fee for the doctor’s services to administer the PSA, but you won’t be charged for the test itself.
Medicare Part B covers your annual DRE screening at 80 percent. This means that after you hit your deductible, you pay 20 percent of the Medicare-approved amount.
If you have Original Medicare and you go to the doctor with prostate cancer symptoms such as painful urination, and the doctor does a diagnostic PSA, Medicare covers 80 percent. This means that after meeting your Medicare Part B deductible, you’ll pay 20 percent co-insurance. If you’re a Medicare Advantage plan member, check your plan coverage rules to find out your cost for diagnostic screenings.
What if your visit starts out as a preventive screening, but the doctor notices signs of cancer and needs to investigate? Anything the doctor does beyond that initial screening will be billed as diagnostic, even if it happens during your initial preventive screening visit.
What Prostate Cancer-Related Services Are Covered?
If the results of your PSA and/or DRE show that you may have prostate cancer, you will likely have more testing, including a biopsy.
If you’re diagnosed with prostate cancer, the treatment plan could include radiation, surgery, hormone therapy, or other approaches. Medicare covers prostate surgery and other possible treatments for prostate cancer just as it does treatments for other cancers. That means inpatient services, possibly including surgery, are covered by Medicare Part A, and outpatient treatments, for example, radiation, are covered by Medicare Part B.
Do You Need to Get Prostate Screening Every Year?
Although Medicare covers annual prostate cancer screening starting at age 50, not everyone will decide to get tested every year. The American Cancer Society recommends that you talk about the pros and cons of screening with your doctor starting at age 50 if you’re at average risk, or earlier if you’re considered high risk. African Americans and men with close relatives who had prostate cancer are considered high risk.
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