Medicare provides its beneficiaries with many different options for helping with the costs of prostate cancer care.
If someone is scheduled for a prostate cancer screening or has recently received a prostate cancer diagnosis, they may be thinking about which treatments, supplies, services, and prescription drugs Medicare may cover.
In this article, we will look at the Medicare coverage available for both the prevention and treatment of prostate cancer. We will also look at general costs, out-of-pocket expenses, and more.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
The prostate is a small, spongy gland approximately the size of a ping-pong ball. It is located deep inside a person’s groin, sitting between the penis and the rectum.
The prostate is important for reproduction because it provides the seminal fluid, which mixes with sperm. Seminal fluid assists the sperm with transport and survival.
If something goes wrong with prostate cells, cancer may develop. Prostate cancer starts when a normal prostate cell shows irregular growth. One of the principal treatments is hormone therapy, which involves lowering a person’s hormone levels with drugs.
Different parts of Medicare cover different treatments and services, depending on their setting.
Medicare Part A
Part A, which is inpatient hospital insurance, covers:
- inpatient hospital admissions, including cancer treatments a person receives during their stay
- skilled nursing facility care following a 3-day hospital stay
- home healthcare, such as rehabilitation services for speech-language, physical therapy, or skilled nursing care
- hospice care
- blood work
- eligible clinical trials
It may be important to note that there are times when hospital stays can be considered outpatient. This may affect Medicare benefits, so if a person is unsure, they may ask the medical staff to clarify.
Medicare Part B
Part B covers outpatient care, including:
- some preventive services for those who are considered at-risk for cancer
- doctor visits
- many intravenous chemotherapy drugs when administered in a doctor’s office
- radiation treatments performed in a clinic
- diagnostic tests such as x-rays and CT scans
- durable medical equipment (DME) such as wheelchairs and walkers
- outpatient surgical procedures
- mental health services that are received in a clinic, doctor’s office, therapist’s office, or hospital outpatient department
- certain preventive and screening services
- some clinical trials
In some cases, Medicare will also cover the cost of a second opinion for non-emergency surgery, and a third opinion if the first and second opinions differ.
Medicare covers prostate cancer screenings for the early detection of prostate cancer. Procedures covered include a digital rectal exam (DRE) and a prostate-specific antigen (PSA) test.
These two screenings are covered yearly for males that are over 50 years of age.
If Part B does not cover a cancer drug, a Medicare Part D plan may provide coverage. Also known as a Prescription Drug Plan (PDP), private insurance companies administer these policies.
A person may check with their plan provider to ensure the plan’s formulary includes the medication they require.
The following cancer drugs may be covered under a PDP:
- oral chemotherapy drugs
- anti-nausea medication
- pain medication
The different screening methods for prostate cancer may differ in cost.
The Medicare Part B coinsurance of 20% applies to a DRE. The deductible may also apply.
If a screening takes place in a hospital outpatient setting, there may also be a copayment due.
A person pays nothing for a yearly PSA blood test if they receive the PSA test from a doctor who accepts assignment.
If the doctor does not accept assignment, an individual may be required to pay an additional fee for doctor services, but not for the test itself.
Copayments, coinsurance, or deductibles may apply to all treatment and care services received.
Costs may depend on several factors, such as:
- whether or not the doctor accepts assignment
- the type of facility a person is attending
- whether a person has another insurance policy
- the location in which a person receives their care
Talking with a healthcare provider to find out how they may charge for a specific prostate cancer-related service may prove helpful.
There are some services that are not covered by Medicare. These include:
- room and board if a person is in an assisted living facility
- adult daycare
- long-term care in a nursing home
- medical food or nutritional supplements
- services that assist a person with activities of daily living, such as bathing and eating
The prostate is a small, spongy gland, situated deep inside the groin of a person with a penis. If something irregular occurs with the prostate cells, cancer may develop.
Medicare covers prostate cancer screening tests and procedures for the early detection of prostate cancer. This includes digital rectal exams and prostate-specific antigen tests.
All parts of Medicare provide coverage for the different treatments and services related to cancer care.
Information and support can be found by visiting the American Cancer Association website, or by calling 800-227-2345.
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