How Does Medicare Cover Prostate Cancer?
By Danielle K Roberts, Guest Contributor
Prostate cancer is a form of cancer that is quite common in men 65 and older. Prostate cancer is the second leading cancer-caused death among men in America. Surviving prostate cancer may require an assortment of treatment plans depending on the stage of the cancer. Since prostate cancer is more common in men age 65 and over, many Americans wonder how Medicare covers treatment and diagnosis of prostate cancer. Here is what you need to know about Medicare and coverage of prostate cancer.
Medicare Coverage of Screenings and Diagnosis
For men over the age of 50, Medicare will cover rectal exams and prostate-specific antigen blood tests once per year. For outpatient digital rectal exams, Medicare Part B will cover 80 percent of medical expenses after the annual deductible is met. Now if treatment is received in an inpatient setting like in a hospital, Medicare Part A will cover it.
Medicare Part A
Medicare Part A falls under Original Medicare and covers hospital inpatient expenses. Part A is premium-free for most Americans who have lived and worked in America for at least ten years and have paid FICA taxes.
Medicare Part B
Part B provides coverage for outpatient medical care. This includes doctor visits, visits to specialists, diagnostic tests and equipment such as durable medical equipment (DME). Medicare Part B is not free and only covers 80 percent of Medicare-approved charges after you meet your annual deductible – you’ll be responsible for the remaining 20 percent not covered. As of 2019, most Americans will spend $135.50/month for premiums and meet an annual deductible of $187.
Medicare Supplement
Being responsible for 20 percent of your cancer treatment can leave you with massive amounts of out- of-pocket costs. This is where a Medicare supplement plan can come into play and truly save the day when it comes to your medical costs.
You can count on the main Medicare Supplement plans, such as Plan F, Plan G and Plan N, to pay the 20 percent that Medicare doesn’t. As Plan F is being phased out in 2020, Medicare Plan G will provide the best value for cancer patients.
Medicare Coverage of Treatment
When it comes to the treatment of cancer, Medicare generally covers all cancer types the same way. If cancer is found, Medicare Part B provides coverage for a variety of different outpatient treatments. For example, oral or vein-administered chemotherapy is covered by Medicare. Medicare Part B benefits will also kick in for outpatient surgery and radiation. If surgery is part of your course of treatment for prostate cancer, Medicare Part A will cover the expense of your inpatient hospital stay. Part A will also cover 20 days in a skilled nursing facility as you recover if you stayed in the hospital for at least three days during your course of treatment.
Part D Coverage
If oral medication is part of your prostate cancer treatment, Medicare Part D may come in effect. Medicare Part D covers retail prescription drugs. Every Part D plan is structured the same, although premiums, covered drugs, and copayments may be different. When your doctor prescribes a new medication, you will want to make sure it’s on your plan’s drug formulary. If the plan doesn’t cover it, you will be responsible for 100 percent of the cost.
Each Part D plan has four stages – a deductible, an initial copay, a coverage gap and catastrophic coverage. Once you’ve met the deductible, you’ll start paying a copay for each drug covered by the carrier.
After you and your plan reach a certain out-of-pocket amount, you’ll shift into the coverage gap, commonly referred to as the donut hole. In the donut hole, you will pay either 25 percent or 37 percent of the total drug cost. After the total out-of-pocket amount reaches a specific amount, you’ll move into catastrophic coverage. During this stage, your drugs will be 95 percent covered, leaving you with a small 5 percent coinsurance charge.
As previously mentioned, Medicare generally covers all cancer treatment the same way, regardless of the type of cancer. However, Medicare doesn’t cover all your medical expenses. If you are diagnosed with prostate cancer and have questions about how your Medicare coverage will apply to your course of treatment, you can reference Medicare.gov or contact your carrier with specific questions.
ABOUT DANIELLE Roberts:
Danielle K Roberts is the co-founder of Boomer Benefits who writes regularly for and is cited by many online publications, including Forbes, where she is a member of the Finance Council. A TCU journalism graduate and former magazine editor, she enjoys sharing her knowledge online.