Does Medicare Cover Prostate Cancer Treatment?
- Learn what Medicare coverage looks like after a prostate cancer diagnosis, and find out what treatment expenses you should expect to pay out of pocket.
When a Medicare beneficiary is diagnosed with prostate cancer, Medicare plans typically take care of some of the costs associated with their treatment. Find out how Medicare covers prostate cancer treatment and look at what you can expect to pay out of pocket when it comes to copayments, deductibles and uncovered expenses.
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Does Medicare Cover Prostate Cancer Treatment?
What medicare covers for prostate cancer treatment depends on the type of coverage you have. Most Medicare Part A plans strictly cover inpatient hospital care. That means you'll have coverage for:
- Hospital admission and treatment received while admitted
- Skilled nursing care or home health care
- Hospice/end-of-life care
- Laboratory blood services
- Some approved clinical trials
If you have Medicare Part B, you can expect it to cover most of your outpatient care services. That includes:
- Visits to an oncologist or primary care physician
- Outpatient surgeries
- Chemotherapy (when administered in a hospital or clinic)
- Radiation (when administered in a hospital or clinic)
- Mental health services
- Diagnostic imaging, such as X-rays
- Durable medical equipment (DME) — this includes walkers and wheelchairs
- Preventive care and screening services
- Some approved clinical trials
As with most chronic illnesses, you'll most likely be required to take prescription medications as part of prostate cancer treatment.
If you have Medicare Part D coverage, you may be eligible for coverage of your cancer drugs, including oral chemotherapy drugs, antiemetics or analgesics when prescribed to treat cancer symptoms or symptoms related to your cancer treatment.
Medicare Part D plans are administered privately so it's best to discuss your coverage with your Medicare Part D provider.
Does Medicare Cover HIFU Treatment?
High-intensity focused ultrasound, or HIFU treatment, is commonly prescribed as an alternative treatment for prostate cancer. This treatment uses highly focused ultrasound to locate and destroy cancer cells. Many doctors prefer this as an initial treatment because it's non-invasive and it doesn't harm healthy tissue or have severe adverse side effects like radiation and chemotherapy often do.
Most Medicare plans do cover a portion of HIFU treatment. As an outpatient procedure, it falls under Medicare Part B. If hospitalization is required during treatment, that portion of the costs would typically be covered under Medicare Part A.
Anticipating Your Out-of-Pocket Costs
There are several costs you'll be expected to cover yourself when it comes to prostate cancer treatment.
Screening Costs
Cancer screenings, including DRE and PSA blood tests, are generally covered under Medicare Part B plans. Your DRE screening may require you to pay a deductible, as well as 20% coinsurance or a copayment. In most cases, PSA tests are covered in full when provided by a physician who has accepted the Medicare rate for this service. If the PSA test is provided by a physician who hasn't accepted the Medicare rates, you might be required to pay a fee for your screening test.
Copayments, Coinsurance and Deductibles
Depending on the coverage you have, you'll likely be required to pay a portion of your treatment costs in copayments, coinsurance and deductibles.
- Copayment: A predetermined and fixed dollar amount that beneficiaries may pay for specific treatments
- Coinsurance: The percentage of treatment costs that a beneficiary must pay out-of-pocket
- Deductible: An annual amount that beneficiaries are required to pay on their own before coverage begins
The best way to determine exactly what your plan will cover is by speaking with your plan administrator or your health care provider.
Additional Care Costs
If you're hospitalized or recovering in any type of long-term care facility, you might be required to pay room-and-board costs, including meals, housekeeping fees, utilities and the cost of your room. Medicare doesn't cover assisted living services, either, so if you're receiving help with grooming or eating, you might need to pay those caregiving costs on your own.
Additionally, if your doctor has prescribed nutritional supplements or a specific diet, your Medicare plan will likely expect you to pay 100% of the cost.
In some cases, these additional expenses might be covered by Medicare Advantage Plans, which are designed to combine Medicare Parts A, B and D, along with supplemental coverage for extra health care services. As these plans vary, it's best to check with your provider to understand what is and isn't covered during hospital or long-term care stays.
About Prostate Cancer
If you or a loved one has been diagnosed with prostate cancer, you might be overwhelmed with thoughts about the future. It may be comforting to know that while prostate cancer is a serious health problem that often requires rigorous treatment, the average 5-year survival rate for localized or regional prostate cancer is close to 100%.
This positive outlook is one of the reasons it's so important for those with prostate cancer to obtain treatment as quickly as possible. In cases where the cancer is diagnosed early, the chances of survival are among the highest.
How Is Prostate Cancer Treated?
There are several options your doctor might consider to treat prostate cancer. Their methods typically depend on how advanced your cancer is, as well as the Surveillance, Epidemiology and End Results (SEER) stage, which determines whether your cancer is localized to one area or has begun to spread throughout the body.
Typical treatments for prostate cancer include:
- Active surveillance
- Hormone therapy
- Radiation
- Chemotherapy
- Surgery
Understanding Medicare Coverage for Prostate Cancer Treatment
While the amount of coverage you'll receive depends largely on your exact plan and the treatment method prescribed by your doctor, most people with prostate cancer find that Medicare does cover prostate cancer treatment relatively well. Although most medical services should be covered by Medicare Part A and Medicare Part B, you might find yourself paying for supplemental care services or prescription medications if you don't have Medicare Part D or Medicare Advantage Coverage.
