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How Does Medicare Cover Prostate Cancer?

According to the Mayo Clinic, there are more than 3 million prostate cancer cases annually. Prostate cancer is a type of cancer that starts in the prostate gland cells and is only found in males. Among those prostate cancer cases, nearly 60% are found in men over 65 years old. If you are 65 years or older, you likely have Medicare as health insurance if you are no longer actively working. Do you know how Medicare Plan B and other plans cover prostate cancer? If not, keep reading to find out.

How Original Medicare covers prostate cancer screenings

Original Medicare has two parts: Part A (inpatient care) and Part B (outpatient coverage). All prostate cancer screenings you receive fall under Medicare Part B, even if you are an inpatient at the hospital. There are two prostate cancer screenings Medicare Part B covers every 12 months for men over 50 years old:

  • PSA blood test: Medicare covers an annual blood test to check for prostate cancer.
  • Digital rectal exam: Medicare covers a yearly digital rectal exam and other Medicare-approved services related to the exam. 
    • When you receive this exam in an outpatient hospital setting, you will pay a separate copayment.

If the digital rectal screening is performed, expect to pay the Part B deductible first. After you pay the Part B deductible, Medicare Part B covers 80% of the prostate cancer screening, and you are responsible for the remaining 20% coinsurance. However, the PSA blood test should not cost you anything. If your doctor does not accept Medicare assignment, you will also pay a 15% Part B excess charge.

Does Medicare cover chemotherapy and radiation?

Chemotherapy and radiation are two methods to treat cancer, including prostate cancer. You will be treated with drugs to kill or shrink the cancer cells when undergoing chemotherapy. Radiation is used to kill the cancer cells with a high-energy beam. Those diagnosed with prostate cancer may be advised to undergo chemotherapy, radiation, or both.

Let’s say you are an inpatient at the hospital and require radiation to treat your prostate cancer. In this case, Part A will cover the Medicare-approved costs of your radiation treatment. You will first pay the Part A deductible, and after that, Part A covers your inpatient stay and Medicare-approved services in full for up to 60 days.

Medicare Part B covers chemotherapy and radiation when you receive the services at an outpatient facility. If you have already met the Part B deductible, you will pay a 20% coinsurance of the Medicare-approved costs.

How does a Medigap plan cover prostate cancer?

As you can tell, Medicare does not cover prostate cancer services entirely, and you will have out-of-pocket costs. Many beneficiaries purchase a Medigap plan, also known as a Medicare Supplement, for secondary insurance. Private insurance companies sell Medigap plans, and there are ten standardized Medigap plans and two high deductible plan options.

Medigap plans do not have network restrictions. Therefore, you can visit any doctor that accepts Medicare in the U.S. for treatment and use your Medigap plan as secondary coverage. If Medicare covers your prostate cancer services, so would a Medigap plan. Many Medigap plans pick up the remaining 20% coinsurance you are initially responsible for.

If you are diagnosed with prostate cancer and want to travel to a U.S. Medicare doctor and have predictable healthcare costs, consider a Medigap plan for secondary insurance.

Do Medicare Advantage plans cover prostate cancer?

Private insurance companies sell Medicare Advantage plans but work entirely differently than Medigap plans. When you enroll in a Medicare Advantage plan, you will receive your Medicare Part A, Part B, and Part D (drug plan) benefits from the insurance carrier. The carrier will create a network of doctors and pharmacies from which you will receive your care, and they will set your cost-sharing amounts.

Every Medicare Advantage plan covers a different set of services, and the plans will have different cost-sharing amounts. For example, Advantage plan A might charge a 20% coinsurance for a prostate cancer screening, whereas Advantage plan B might set a flat copay of $60 for a screening. But know that Medicare Advantage plans have a maximum out-of-pocket (MOOP) limit. In 2022, the MOOP is $7,550. Once you and your plan meet the MOOP, your plan will begin paying the total cost of your covered services.

You can find the covered services and cost-sharing amounts in the Advantage plan’s Summary of Benefits letter. So, if you are diagnosed with prostate cancer, refer to this letter to know how your plan will cover you.

Prostate cancer medications

Original Medicare Part A and Part B do not cover prescriptions you pick up at the pharmacy. Due to this, private insurance carriers sell Part D drug plans for prescription coverage. Every Part D plan has a drug formulary. The drug formulary displays the medications the Part D plan will cover for that year.

If you are diagnosed with prostate cancer, and your doctor prescribes you a medication, you can check the plan’s drug formulary to know if your plan covers the drug. If the needed medication is not listed on the formulary, your doctor would want to submit a drug exception so you can have coverage from your plan.

Wrapping up

All in all, Original Medicare does cover prostate cancer. But you will have out-of-pocket costs for the Medicare-approved services. To avoid high out-of-pocket costs, work with a reputable Medicare broker to find you a Medigap or Medicare Advantage plan for cost-sharing help.

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