Insurance Coverage for Prostate Cancer Screening

The American Cancer Society (ACS) supports legislation assuring that men have insurance coverage for prostate screening exams.

Men should have the option of screening

ACS recognizes that it’s not yet clear whether screening lowers the risk of dying from prostate cancer. Until such time when studies are conclusive, men and their doctors should be free to determine if testing is right for them. Men shouldn’t be prevented from getting prostate cancer screening because of testing costs, lack of health insurance coverage, or lack of access to testing.

ACS doesn’t recommend routine screening for prostate cancer for all men at this time, because we believe proper guidance and education is needed before testing is done. Doctors and other health care providers should help men understand the potential risks and benefits of prostate-specific antigen (PSA) testing, allowing them to make an informed decision on testing.

State efforts to ensure prostate cancer screening coverage

Many states have laws requiring private health insurers to cover tests to detect prostate cancer, including the PSA test and digital rectal exam (DRE). Some states also assure that public employee benefit health plans provide coverage for prostate cancer screening tests.

Most state laws assure annual coverage for men ages 50 and over and for high-risk men, ages 40 and over. “High-risk men” typically refers to African American men and/or men with a family history of prostate cancer. Some states have slightly different coverage requirements.

Laws on coverage vary from state to state, so check with your insurer or with your state insurance commissioner’s office to learn what’s covered.

Medicare coverage

Medicare covers a PSA blood test and a DRE once a year for all men with Medicare age 50 and over.

PSA test: You pay nothing for a yearly PSA blood test. If you get the test from a doctor who doesn’t accept assignment, you may have to pay a fee for the doctor’s services, but not for the test itself.

Digital rectal exam: If your doctor does this test, you pay 20% of the Medicare-approved amount for a yearly DRE and for your doctor’s services related to the exam. The Part B deductible applies. If the DRE is done in a hospital outpatient setting, there is a copayment.

Medicaid coverage

Medicaid coverage of prostate cancer screening varies by state.

People who qualify for Medicaid based on their state’s decision to expand Medicaid under the Affordable Care Act (ACA) are entitled to the same screening services as people covered by private insurance.

For people who qualify for Medicaid based on other pathways, prostate cancer screening coverage is determined by the state. Most Medicaid programs do cover screening.

To learn more about prostate cancer screening coverage in your state, contact your state’s Medicaid office.