Does Medicare Cover Urology?
This article was updated on: 05/28/2019
Are you wondering what urology is and whether urologic services are covered by Medicare? By definition, urology involves conditions of the urinary and male reproductive systems.
If you’re a Medicare beneficiary with a urologic condition and need to see a physician who specializes in urology, the urologist’s services may be covered by Medicare Part B (medical insurance). If you need to stay at the hospital, inpatient services in a Medicare-certified hospital may be covered by Medicare Part A (hospital insurance). You can consult with your urologist about specific health problems and what course of treatment is recommended. Be sure to ask if Original Medicare (Medicare Part A and Part B) covers the recommended urologic services and if you’ll have out-of-pocket costs.
Learn more about urology and Medicare coverage for urologic conditions.
Definition of urology
The American Urological Association (AUA) gives the following definition of urology: “Urology is a surgical specialty which deals with diseases of the male and female urinary tract and the male reproductive organs.”
A urologist may diagnose and treat a variety of medical conditions such as:
- Kidney stones
- Urinary tract infections
- Bladder control problems
- Male sexual dysfunction and infertility
- Prostate cancer
What are urologic conditions?
The broad definition of urology is the study of diseases of the urinary tract and the male reproductive system. However, there can be a variety of clinical problems within urology, and the American Urological Association (AUA) has identified the following seven subspecialty areas:
- Calculi (urinary tract stones): Kidney stones can pass down into the ureter (the channel that passes urine from the kidneys to the bladder); larger stones may get stuck and block the flow of urine, causing severe pain.
- Female urology: This can include bladder control problems or pelvic outlet relaxation disorders.
- Male infertility: Infertility is a term that doctors use if a man hasn’t been able to get a woman pregnant after at least one year of trying.
- Pediatric urology: This includes treatment of urological disorders in children, including bedwetting.
- Neurourology: This can include erectile dysfunction or impotence.
- Renal (kidney) transplantation: Kidney transplantation surgery may be necessary in the event of kidney failure.
- Urologic oncology (cancer): This can include treatment of prostate or bladder cancer.
Medicare coverage of urological services
Original Medicare, Part A and Part B, covers a variety of hospital and medical services if you need treatment for urological conditions.
If your treatment requires a hospital stay, inpatient services may be covered by Medicare Part A (hospital insurance). Urologists also offer outpatient services that may be covered by Medicare Part B, including doctor services, lab tests, X-rays, and more.
The type of urology treatment you may need will depend on the specific urological condition you have. For urological surgeries or procedures, be sure to ask the doctor, hospital, or facility how much you’ll have to pay for surgery and post-operation care. You should also ask if you’re an inpatient (formally admitted to the hospital with a doctor’s order) or an outpatient because this will affect your costs under Medicare.
In order to minimize your out-of-pocket costs for your urology treatment care, make sure that the hospital or doctor accepts Medicare assignment; this means that the provider agrees to accept the cost that Medicare has set for the service as full payment and won’t charge you above this amount (although you’re still responsible for cost sharing). Your out-of-pocket cost sharing could include copayments, coinsurance, and/or deductibles, so it’s a good idea to ask what specific urology treatments are covered and for how long before you proceed.
Medicare coverage of prostate cancer screenings
Your health care provider can perform yearly prostate cancer screenings, which are covered by Medicare Part B for all men over age 50. There are two types of covered screenings:
- Prostate Specific Antigen (PSA) test: The yearly PSA blood test is covered and usually has no cost, unless your provider does not accept assignment. Then, you may pay a fee for the doctor services (but not for the actual test).
- Digital rectal exam: You’re covered once every 12 months. For this exam, you will need to pay 20% of the Medicare-approved amount, as well as for the doctor services. Please keep in mind that the Part B deductible applies, and if you have the exam in a hospital outpatient setting, you’ll also have a copayment.
Medicare prescription drug coverage to treat urological conditions
Depending on the type of urological condition you have, your urologist may prescribe medications as part of your treatment. If you’re enrolled in Original Medicare, prescription drug benefits are limited, and you may want to sign up for prescription drug coverage (Medicare Part D), which works alongside your Part A and Part B benefits. You can get this by enrolling in a stand-alone Medicare Prescription Drug Plan.
As another option, you can also get prescription drug coverage through a Medicare Advantage Prescription Drug plan. A Medicare Advantage Prescription Drug plan is an alternative method to receive your Original Medicare benefits and may also include additional benefits not covered under Part A and Part B, including prescription drug coverage.
Medicare Prescription Drug Plans and Medicare Advantage plans are offered through Medicare-approved private insurance companies. These plans come with their own costs and, depending on the plan, may lower how much you pay out of your own pocket for urological services.
Hopefully, you now have a better idea of what urology is and what Medicare covers when it comes to urological services and treatment. If you think you may want to enroll in a Medicare Advantage Prescription Drug plan or a stand-alone Medicare Prescription Drug Plan, the Annual Election Period (October 15 to December 7) is the best time to do so. However, if you have a qualifying situation, you may be able to make changes to your coverage through a Special Election Period.
Do you have questions about plan options or when you can enroll in Medicare plan options that may cover urological services you need? I can help you get started.
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For more information on urology, see:
American Urological Association, “What is Urology?” https://www.auanet.org/about/what-is-urology.cfm
This website and its contents are for informational purposes only. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.