The Prostate-Specific Antigen (PSA) test is a common blood test used to screen for prostate cancer, measuring the level of a protein produced by cells in the prostate gland. Elevated PSA levels may indicate cancer, but they can also be caused by non-cancerous conditions like an enlarged prostate or inflammation. Understanding how Medicare covers this preventive screening is important for beneficiaries, as coverage is defined by specific rules regarding eligibility, frequency, and financial obligation.
Initial Eligibility Requirements for Coverage
Medicare covers the PSA screening test under its medical insurance component, Medicare Part B, as a preventive service. Coverage for the screening is limited exclusively to male Medicare beneficiaries who have attained the age of 50 or older. To ensure the test is covered, it must be ordered by a physician or other qualified non-physician practitioner who is legally authorized to do so. The test is considered a benefit for all qualifying male beneficiaries, regardless of whether they have a family history or other risk factors for prostate cancer.
Medicare’s Frequency Rule for PSA Screening
The core rule governing how often Medicare pays for a screening PSA test is strictly limited to one test every 12 months. The 12-month period is calculated from the date of the patient’s last covered screening, meaning a full year must pass before the next test is authorized for payment. The coverage also includes a yearly digital rectal exam (DRE) for those who meet the eligibility criteria.
Screening vs. Diagnostic Tests
It is important to understand the distinction between a routine screening test and a diagnostic test. If a patient’s initial screening test shows an elevated PSA level, any subsequent follow-up tests, like a free PSA test, MRI, or biopsy, are considered diagnostic. These diagnostic services are covered under a different set of Part B rules because they are used to diagnose a specific condition, not simply to screen for one. While the annual screening is covered, any diagnostic tests required due to symptoms or an abnormal screening result will fall under the standard Part B cost-sharing framework.
Patient Financial Responsibility
The primary screening PSA blood test is covered at no cost to the beneficiary when the requirements for eligibility and frequency are met. If the healthcare provider accepts the Medicare-approved amount, the patient pays zero dollars, meaning there is no coinsurance, copayment, or deductible applied to the laboratory test itself. This zero-cost sharing applies to the blood draw and the laboratory analysis for the PSA level.
However, the cost of the office visit necessary to order the test may not be fully covered. If the PSA screening is performed during a routine Annual Wellness Visit or a Welcome to Medicare preventive visit, all costs related to the visit are typically covered. If the test is ordered during a regular office visit for other medical issues, the patient may still be responsible for the standard Part B deductible and the 20% coinsurance for the physician’s service.
Beneficiaries enrolled in a Medicare Advantage Plan (Part C) or who have a Medicare Supplement Insurance Plan (Medigap) may have different out-of-pocket costs. Medicare Advantage plans must offer at least the same benefits as Original Medicare, but they may have different cost-sharing rules and network requirements. Medigap policies can help pay for the 20% coinsurance and the deductible associated with any related physician visit or diagnostic follow-up test.