Does Medicare Cover a PSA Test?
Medicare Benefits Solutions
Apr 5, 2021
Are you wondering if a PSA test is covered by Medicare? Part B covers preventive screenings for different types of cancer, cardiovascular disease, diabetes, HIV, glaucoma, and more. With over 250,000 new cases of prostate cancer diagnosed in 2022, routine screenings can be an important step in detecting the disease and getting early treatment.
What is a PSA Test for Prostate Cancer Screening?
PSA stands for prostate-specific antigen. An antigen is a substance that causes the body to produce antibodies. The prostate gland is an integral part of the male reproductive system, and elevated PSA levels suggest an abnormality in the gland.
The PSA test is a blood test to identify or rule out prostate cancer. A healthy prostate produces a small amount of PSA. A high level of PSA serves as a warning sign of possible:
- Prostate cancer
- Benign enlargement of the prostate gland
- Inflammation of the gland, known as prostatitis
Doctors may perform these tests in their offices, or they may direct you to go to a lab. Although a high PSA level may indicate cancer, the test does not show the type of cancer cells present, so it’s important to talk to your doctor about further testing as needed.
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Does Medicare Pay for a PSA Test?
Medicare helps pay for digital rectal exams and PSA blood tests to test for prostate cancer. Medicare pays the total cost for the PSA test as part of Medicare preventive screenings as long as you visit a physician that accepts assignment.
If you have Part B and use a healthcare provider who accepts assignment, you will incur no out-of-pocket expense for the covered PSA test. Participating doctors and healthcare facilities accepting assignment are contractually bound not to charge you more than Medicare will allow. If you choose to visit a doctor that does not accept assignment, you may have to pay a fee for the doctor’s services.
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How Often Will Medicare Pay for a PSA Test?
Men are eligible for a PSA test once every 12 months after the age of 50. The day after you turn 50, you are eligible for your first annual prostate cancer screening at no cost. “Prostate cancer is the second leading cause of cancer death in American men, behind only lung cancer,” according to the Urology Care Foundation. Screenings are important because you may not have symptoms during the early stage of the disease when it is most treatable.
What Age Does Medicare Stop Paying for PSA Test?
Medicare has not published an age cap on coverage for a PSA test. The American Urological Association (AUA) commissioned a group of experts to research prostate cancer detection and screening. Findings that grew out of this research led to the following screening guidelines that should be part of a doctor-patient discussion:
- Under age 40: No PSA screening
- Age 40 through 54: Screening for high-risk men, based on demographic race and family history
- Age 55 through 69: Screenings strongly encouraged
- Age 70 and older: Not recommended
How Much Do Prostate-specific Antigen Tests Cost?
The cost of medical services without insurance in the U.S. varies from one state and medical practice to another. An accredited charity, ZERO – The End of Prostate Cancer, maintains an online database of cancer testing sites around the country, and some may offer free testing.
If you have Medicare, your cost will vary based on several factors:
- Your Medicare plan (if you have Original Medicare, Medicare Advantage, or Medigap)
- Whether or not your doctor accepts assignment and, for MA plan members, if the doctor is in-network
- Where the test is performed (doctor’s office, lab, outpatient facility)
If you are getting the test in a hospital, keep in mind that all U.S. hospitals are required to provide pricing information online.
Does Medicare Advantage Cover Prostate Cancer Screenings?
Medicare Advantage (MA) plans cover at least the same benefits as Original Medicare. If Original Medicare covers a medical service, MA plans will cover the service as well, though your deductible, coinsurance and copayment may be different. MA plans may set their own rules to expand benefits but cannot offer less than Original Medicare. Your Evidence of Coverage contains benefit details.
MA plan members may have to use network doctors exclusively to get coverage. Some plans, such as a PPO, may allow you to go outside network for a higher cost. Check your plan’s requirements and network provider directory.
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How Do Medigap Plans Cover PSA Tests?
Medigap, also known as Medicare Supplement, plans help cover Medicare-approved, out-of-pocket expenses that Original Medicare does not include. Policies vary in the extent of benefits covered. Some plans cover Part B coinsurance and copayments. Although cost-sharing does not apply to PSA tests, you may be able to use Medigap benefits for the digital rectal exam.
The digital rectal exam is also a preventive prostate cancer screening service covered under Part B. Men over 50 are eligible for the exam every 12 months. The Part B deductible applies, and you are obligated to pay 20% of the Medicare-approved amount. Additionally, if you have the exam in a hospital outpatient setting, the facility may charge you a copayment.
How Do you Get Coverage for PSA Tests?
Enrolling in Medicare is the first step toward getting coverage for PSA tests. If you enroll in a Medicare Advantage plan, your benefits may be more robust than the Original Medicare program. Medicare designates an annual Open Enrollment Period each year so that you can explore your plan options and switch plans if you choose to.
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