Prostate Cancer Screening: What Medicare and ACA Plans Cover
September is a great time to focus on men’s health and preventive care. Prostate cancer is one of the most common cancers among men, and regular conversations with your healthcare provider can help you understand your personal risk and whether screening is appropriate for you. Understanding how your health insurance covers prostate cancer screening can also help you make informed decisions about your health. Medicare and Affordable Care Act (ACA) plans both provide coverage for certain preventive services, but the details can differ.
What Is Prostate Cancer Screening?
Prostate cancer screening is used to look for signs of prostate cancer before a man has symptoms. The two most commonly discussed screening methods are:
- PSA blood test: Measures the amount of prostate-specific antigen (PSA) in the blood. An elevated PSA level does not necessarily mean that a man has prostate cancer, but it may indicate that additional testing is needed.
- Digital rectal exam (DRE): A healthcare provider examines the prostate for abnormalities. Whether and when a DRE is recommended depends on a man’s individual circumstances.
Screening decisions should be made with your healthcare provider. Your age, family history, race, overall health, and other risk factors may affect when screening should begin and how often it should be performed.
How Does Medicare Cover Prostate Cancer Screening?
Medicare Part B covers a PSA blood test once every 12 months for men age 50 and older when the test is used for prostate cancer screening and is ordered by a qualified healthcare provider. When Medicare covers the PSA test as a preventive screening service, you generally pay nothing for the test when your provider accepts Medicare assignment. The Medicare Part B deductible does not apply to this covered preventive screening. It’s important to understand that screening and diagnostic testing are not the same. If your doctor orders additional tests because you have symptoms or an abnormal PSA result, different Medicare cost-sharing rules may apply.
How Do ACA Marketplace Plans Cover Prostate Cancer Screening?
ACA Marketplace health plans are required to cover certain preventive services without cost-sharing when the services are recommended by the U.S. Preventive Services Task Force (USPSTF) and are provided by an in-network provider. However, prostate cancer screening is a little different. The USPSTF recommends individual decision-making for men ages 55 to 69 about whether to undergo periodic PSA-based screening. For men age 70 and older, the USPSTF recommends against routine PSA-based screening. Because of these recommendations, coverage and cost-sharing for prostate cancer screening under an ACA plan can depend on the specific plan and circumstances. If you’re considering a PSA test, check your plan’s benefits or talk with your insurance agent and healthcare provider before scheduling the test.
Why Preventive Care Matters
Preventive care gives you the opportunity to identify potential health concerns early and have a conversation with your healthcare provider about the best course of action. A PSA test is not a perfect test, and an elevated result can have several causes besides cancer. That’s why discussing your individual risks and the potential benefits and drawbacks of screening with your healthcare provider is important. Your health insurance coverage is also an important part of your preventive-care planning. Knowing what your plan covers—and whether a service is considered preventive or diagnostic—can help you avoid unexpected medical bills.
Talk With Your Healthcare Provider
There is no single screening schedule that is right for every man. If you’re concerned about prostate cancer or have questions about your risk, talk with your healthcare provider. Be sure to mention any family history of prostate cancer and discuss when screening may be appropriate for you. We help individuals understand their Medicare and health insurance coverage so they can make informed decisions about their healthcare. If you have questions about what your plan covers, we’re here to help you understand your benefits. Coverage rules and preventive-care recommendations can change. Always verify your specific benefits with your health plan and healthcare provider. Click here to contact us for more information.
Take this quiz to see how much you know about prostate cancer. Prostate Cancer Quiz | Test Yourself on Prostate Cancer | American Cancer Society