Does Medicare Cover a PSA Test?

By - April 5, 2021

Cancer is a disease that is best treated before it spreads. Early stages of prostate cancer may not present signs and symptoms. The initial tests doctors usually perform to detect prostate cancer are the digital rectal exam and prostate specific antigen (PSA) blood test. 

Prostate cancer is a disease of the prostate, a male gland situated below the bladder and in front of the rectum. The American Cancer Society reports that prostate cancer is second to skin cancer as the most common type of cancer among men. It is predominant in older men. The good news is that treatments are often successful. The most common treatments are close monitoring, surgery and radiation therapy.

PSA blood test

The cells in your prostate gland produce a protein known as PSA. Though mostly found in semen, a lesser amount is found in the blood. If the PSA level in the blood rises, your doctor may suggest a PSA blood test. Though there is no fixed cutoff point, many health care practitioners recommend the test when PSA reaches 4 nanograms per milliliter (ng/mL) of blood. Depending on the results, your doctor may recommend further testing. According to the American Cancer Society, "if the PSA is more than 10 ng/mL of blood, the chance of having prostate cancer is over 50%."  

The National Cancer Institute warns that finding the cancer may not improve your health or longevity if the disease has already spread beyond the prostate. If the PSA level is higher than normal, a biopsy may be the next step, and biopsies can lead to complications. Also, be aware that PSA tests can be misleading, giving false-negative or false-positive results. Before you schedule prostate cancer screening, discuss the possible outcomes and risks with your doctor.

Medicare benefits for prostate cancer screenings

Under Medicare Part B benefits, men are eligible for rectal exams and PSA blood tests. These screenings are covered every 12 months. Medicare is specific on when you become eligible. This is a benefit "for men over 50 (beginning the day after your 50th birthday)."

Your costs for prostate exams and tests

As long as your doctor accepts assignment, you should not be billed anything for the annual PSA blood test. Assignment means that your doctor agrees to accept direct payment from Medicare and cannot charge you a higher fee. 

For the digital rectal exam, you are responsible for coinsurance. This is 20% of the amount Medicare approves for the exam and related services that your doctor provides. Your Part B deductible must be met first. The 2021 deductible is $203. If the test is performed in a hospital outpatient setting rather than a doctor's office, the facility will likely require a copayment. 

Note that a copayment (copay) is different from coinsurance. Both payments represent your share of the cost. The coinsurance is a percentage of the Medicare-approved amount, which you pay in addition to meeting your deductible. A copay is a set amount, usually a nominal fee, irrespective of the deductible.

If you are enrolled in a Medicare Advantage plan, you will have at least the same benefits as Original Medicare Part A and Part B, but many MA plans will offer additional coverage. Check with your plan directly for specific information. 

Resources

Credible sources for information about prostate cancer include the Centers for Disease Control and Prevention (cdc.gov/cancer/prostate/basic_info/what-is-prostate-cancer.htm), the National Cancer Institute (cancer.gov/types/prostate/patient/prostate-screening-pdq#_35) and the American Cancer Society (cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/tests.html).

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