Does Medicare Cover Prostate Exams?

Tamera Jackson by Tamera Jackson | Licensed since 2007
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This article was updated on: 09/10/2018

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Prostate cancer is the second most common cancer in men and the third leading source of cancer deaths among men in America according to the American Cancer Society. Fortunately, if you are a Medicare beneficiary, Medicare covers prostate exams and certain tests to screen for prostate cancer ordered by your doctor. Find out what you need to know about prostate exams and Medicare coverage.

 What is a prostate exam?

There are two main types of screening prostate exams, the PSA test and the digital rectal examination. Your doctor may recommend one or both of these tests, depending on your medical history and symptoms.

PSA TestThe PSA test is a simple blood test that detects the level of prostate-specific antigens (PSA) in your bloodstream. In healthy men, the PSA value is lower than 4 ng/mL. If your PSA level is above 4 ng/mL, you doctor may want to do other types of prostate exams, such as a digital rectal exam, to check for prostate cancer.

Digital Rectal Exam (DRE): During a digital rectal prostate exam, your doctor inserts a gloved and lubricated finger into your rectum to feel for any lumps, hardness, or irregularities in your prostate. If your doctor finds any signs of disease during the digital rectal prostate examination, he or she may recommend you have other diagnostic tests such as a prostate ultrasound or a biopsy.

Who should get a prostate exam cancer screening

Most health experts recommend routine annual prostate exams for men once they reach their 50th birthday. In some cases, men at higher risk for prostate cancer may get prostate exams even sooner. Risk factors for prostate cancer include:

  • Age—your risk for prostate cancer goes up as you get older.
  • Family history—if a close family member has had prostate cancer, your risk is higher.
  • Ethnic minority status—certain ethnic groups, including African Americans, are at higher risk for the disease.

You should follow your health-care provider’s recommendations for prostate exams, since in some cases, there are no detectable symptoms with prostate cancer.

Medicare coverage for prostate exams?

Part B covers certain preventive services, including prostate exam screenings. All male beneficiaries over 50 with Part B are covered, starting the day after their 50th birthday. Under Medicare Part B, an annual PSA screening test is covered every 12 months for free if your doctor accepts Medicare assignment. If your doctor does not accept Medicare, you may pay a fee for the physician services, but not for the blood test itself.

Medicare also pays for one digital rectal prostate exam each year. If the test is performed at your doctor’s office, you pay 20% of the Medicare-approved charges, after you’ve reached the Part B deductible. If the prostate exam is performed in a hospital outpatient department, you pay a copayment.

If you need more information about prostate examinations and your Medicare coverage, I would be happy to talk with you and answer your questions. I can also explain some of your other Medicare coverage options, including Medicare Advantage plans, which cover the same benefits as Original Medicare, including preventive services. Many Medicare Advantage plans also offer additional benefits, such as prescription drugs or routine vision or dental.

You can schedule a phone call or request an email with personalized information by clicking one of the links below. To view plan options in your area that you may be eligible for, click the Compare Plans button.

 

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