Does Medicare Cover Prostate Cancer Screenings?
Medicare covers two common screening tests for prostate cancer: The prostate specific antigen, or PSA, test and a digital rectal examination. You can receive a free annual PSA test at no cost to you. You will owe 20 percent for digital rectal exams, and the Part B deductible applies.
How Prostate Cancer Screenings Work
Prostate cancer is the second most common cancer in American men.
According to the U.S. Centers for Disease Control and Prevention, 13 out of every 100 American men will get prostate cancer during their lifetime — and about two to three men will die from the disease.
Age is the most common risk factor. The older a man is, the more likely he is to develop prostate cancer.
There is no standard test to screen for prostate cancer, but the two most common are the prostate specific antigen, or PSA, test and a digital rectal examination.
Prostate Specific Antigen Test
A prostate specific antigen, or PSA, is a substance created by the prostate.
Generally, the higher the PSA level is in your blood, the more likely a prostate problem exists.
But PSA may also be elevated in other conditions that affect the prostate.
- Certain medical procedures
- Certain medications
- An enlarged prostate
- An infection
When used in conjunction with other prostate cancer tests — such as a digital rectal examination — PSA tests can aid in the decision-making process for diagnosing prostate cancer.
If your PSA test is abnormal, your doctor may recommend a biopsy to determine if you have prostate cancer.
Digital Rectal Examination
A digital rectal examination allows a medical professional to check your prostate for nodules or other abnormalities.
The examination is performed when a health care provider inserts a gloved, lubricated finger into a man’s rectum to feel the prostate for any abnormalities, such as cancer.
In 2018, the U.S. Preventive Services Task Force stated that it does not recommend digital rectal examinations as a screening tool due to a lack of evidence on its benefits.
Medicare Coverage of Prostate Cancer Screenings
Medicare provides coverage for digital rectal exams and prostate specific antigen blood tests once every 12 months for all male beneficiaries ages 50 and older.
The PSA blood test must be ordered by your doctor or a qualified nonphysician practitioner.
The digital rectal exam must be performed by a doctor or practitioner who is authorized by Medicare to complete the examination.
While Medicare covers PSA tests and digital rectal exams, you will likely pay different amounts for these services.
- Digital Rectal Exam
- You will owe a 20 percent coinsurance payment for the Medicare-approved cost for a yearly digital rectal examination and for your doctor's services related to the exam. The Part B deductible — $203 in 2021 — also applies. If the test takes place in a hospital outpatient setting, you may also owe a copayment.
- PSA Test
- You pay nothing for a yearly PSA blood test. All coinsurance payments and deductibles are waived for this test.
Medicare Advantage plans, which are administered by private insurance companies that contract with the federal government, offer the same prostate cancer screening coverage and costs as Original Medicare.
5 Cited Research Articles
- American Cancer Society. (2021, January 12). Key Statistics for Prostate Cancer. Retrieved from https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html
- Centers for Disease Control & Prevention. (2020, August 18). What Is Prostate Cancer? Retrieved from https://www.cdc.gov/cancer/prostate/basic_info/what-is-prostate-cancer.htm
- Centers for Disease Control & Prevention. (2020, August 18). What Is Screening for Prostate Cancer? Retrieved from https://www.cdc.gov/cancer/prostate/basic_info/screening.htm
- Centers for Medicare & Medicaid Services. (n.d.). National Coverage Determination (NCD) for Prostate Cancer Screening Tests (210.1). Retrieved from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=268
- Medicare.gov. (n.d.). Prostate cancer screenings. Retrieved from https://www.medicare.gov/coverage/prostate-cancer-screenings