CANCER AND MEDICARE SERIES

YOUR PROSTATE AND MEDICARE

Between 60 & 70% of newly diagnosed cancers occur with folks age 65 and older. 

The median age for a cancer diagnosis is roughly 66–67 years. Common cancers in this age group include breast, colorectal, lung, and prostate, with a noted spike in diagnoses at age 65, often linked to Medicare eligibility.

Medicare generally does not pay for experimental or investigational treatments, as it only covers services deemed "reasonable and necessary". However, Medicare does cover routine costs (doctor visits, hospital stays, tests) associated with approved, qualifying clinical trials. The experimental drug or device itself is usually not covered.

If you enroll in a Medicare Advantage plan that policy REPLACES original Medicare Parts A & B. Medicare Advantage becomes your PRIMARY coverage and original Medicare no longer provides your benefits nor do they adjudicate or pay your medical claims. When you have an Advantage plan you are still responsible for premiums charged by Medicare A and B. SOME Advantage plans may rebate a portion of your Part B premium.

Medicare supplements (Medigap) play a role that is SECONDARY to original Medicare. When you have a Medigap plan, original Medicare is your PRIMARY coverage, Medigap is secondary. 

Medicare supplement plans (Medigap) only pay “spillover” claims (deductibles, copays, coinsurance) adjudicated and approved by Medicare.

Future newsletters will focus on medical conditions common to those of us on Medicare. Some of the topics considered include . . . breast cancer, colorectal cancer, lung cancer, cataracts, glaucoma, immunotherapy, kidney care and more.

Comments, suggestions and feedback appreciated.

DISCLAIMER

These newsletters should not be considered medical advice. They are researched and published as an information resource. Your physician should always be your primary source regarding health issues.

Ladies, this topic does not directly affect you so you may want to share this with men you know. Prostate cancer is mostly an “old man disease” but men as young as 40 can develop cancer.

DOES MEDICARE COVER PROSTATE CANCER DIAGNOSIS AND TREATMENT

Medicare covers prostate cancer diagnosis (screenings like PSA tests, DREs, biopsies) and treatment (surgery, radiation, chemo, hormone therapy, etc.), with different parts handling different services (Part B for outpatient/doctors, Part A for inpatient), but you'll pay coinsurance, deductibles, and potentially for experimental care.

Diagnosis & Screening

Prostate-Specific Antigen (PSA) Test: Covered annually for men over 50 (you generally pay nothing for the test, but may pay for the doctor's visit).

Digital Rectal Exam (DRE)

Diagnostic Tests

https://www.healthline.com/health/medicare/does-medicare-cover-psa-test#coverage-for-additional-tests

If your doctor believes your situation could be an exception to the guidelines, the doctor or lab should present you with an a Medicare ABN form (Advance Beneficiary Notification) that your test may not be approved for coverage by Medicare

Treatment (Original Medicare - Parts A & B)

https://www.healthline.com/health/medicare/does-medicare-cover-prostate-surgery#covered-procedures

Costs & Considerations

You'll typically pay 20% coinsurance for Part B services after your deductible, and potentially for some services during a screening.

Medicare usually doesn't cover experimental treatments, but may approve some.

Medicare Advantage (Part C): Plans must offer similar coverage but have different costs/rules.

Medicare Supplement (Medigap): Plans can help pay your out-of-pocket costs (deductibles, coinsurance) for tests & treatment approved by Medicare

NOTE: Your doctor may recommend services that Medicare does not cover or offers too frequently. This could end up in additional costs for you. Make sure to ask your doctor about the reasons for these recommendations and what Medicare will actually cover.

Something to try on your next vacation . . .

CAN I GET A PSA TEST AFTER AGE 70?

There's no universal "no" for PSA tests after 70, but major guidelines like the U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for men 70+ because potential harms (false positives, anxiety, biopsies, overtreatment of slow-growing cancers) often outweigh benefits, as many men die from the procedures rather than from prostate cancer. However, the decision is increasingly personalized, with some doctors continuing screening for healthy men with high life expectancy or rising PSAs, especially with family history or African American ancestry, requiring shared decisions with a doctor.  

https://www.cdc.gov/prostate-cancer/screening/get-screened.html

Something to remember . . .

CAN I GET A PSA TEST MORE THAN ONCE A YEAR

Medicare generally covers one PSA (Prostate-Specific Antigen) test annually at no cost as a preventive screening, but if your doctor deems more frequent testing medically necessary (e.g., for high-risk individuals or monitoring elevated levels), Medicare Part B can cover additional tests, though you might pay coinsurance or deductible, as they become "diagnostic" rather than purely preventive. 

https://www.mdanderson.org/cancerwise/prostate-specific-antigen--psa--levels-by-age--what-to-know.h00-159695967.html

DOES MEDICARE PAY FOR HORMONE THERAPY FOR MEN WITH PROSTATE CANCER

Medicare generally covers hormone therapy for prostate cancer, but coverage depends on the administration method: Part B covers injections/infusions in a doctor's office, while Part D typically covers take-home prescriptions like pills, with costs varying by plan formulary.

How Medicare Covers It:

https://quickrxspecialty.pharmacy/navigating-lupron-prescriptions-with-medicare-part-b-and-part-d/

Key Considerations:

Formulary: Verify if the specific hormone drug is on your Part D plan's formulary.

Costs: Expect deductibles, coinsurance (20% for Part B), and copays; Medicare Supplement (Medigap) plans can help cover these costs. Medicare Advantage typically charges you for the 20% coinsurance up to your MOOP (maximum out of pocket).

Even if you don’t like mime’s . . .

DOES MEDICARE PAY FOR ALTERNATIVE FORMS OF THERAPY FOR MEN WITH PROSTATE CANCER

Medicare generally pays for proton therapy for prostate cancer when a doctor deems it medically necessary. Medicare also covers FDA-approved immunotherapy (such as sipuleucel-T/Provenge) for men with certain types of advanced or metastatic prostate cancer.   covering it under Part B (outpatient) or Part A (inpatient) depending on where treatment occurs, though patients are responsible for deductibles, premiums, and 20% coinsurance for Part B, with potential supplemental costs. Coverage often involves pre-authorization, and costs can be significantly reduced with Medicare Advantage or supplemental plans, but verifying with the provider and plan is crucial. Prior authorization is often required with Advantage plans. Providers who accept Medicare assignment will also take your Medigap plan.

How Medicare Covers It

Medical Necessity: Medicare covers proton therapy as a form of radiation therapy when it's considered medically necessary and offers benefits (like sparing healthy tissue) over other treatments.

Costs & Your Responsibility

Out-of-Pocket Costs: Even with coverage, you'll pay your Part B deductible, and 20% of the Medicare-approved amount for the treatment.

Supplemental Insurance: Medigap (Medicare Supplement) plans can significantly lower your out-of-pocket costs. 

Medicare Advantage is primary coverage, not supplemental to original Medicare. Prior authorization may be required.

Before Starting Treatment

Confirm with Your Provider: The cancer center's financial team will work with Medicare to get authorization and confirm coverage details.

Check Your Plan: Always understand your specific Medicare Advantage plan's rules for radiation therapy.

One more . . . Eye of the Tiger

LINKS EXPLAINING IMMUNOTHERAPY

Among treated patients, 92% were recurrence-free at two years, and 82% did not undergo surgery. This included 35 to 54 patients who had tumors in their stomach, esophagus, liver, endometrium, urinary tract and prostate.

https://www.beckershospitalreview.com/quality/infection-control/immunotherapy-may-replace-surgery-for-some-cancer-patients-3-notes/

A NOTE ABOUT MEDICARE.GOV CLAIM SUMMARY ISSUES

Medicare has not permanently stopped showing claim summaries online, but beneficiaries have reported significant, ongoing issues Medicare.gov website not updating with recent claim activity, particularly around late 2025 and early 2026. 

Based on user experiences and reported issues, the delay or disappearance of claims in online portals stems from several factors:

Systemic Delays and Technical Issues: Many users have reported that as of late 2025, the Medicare.gov website stopped posting recent claim activity in real-time, often leaving accounts showing no new claims for months.

Impact of Cyber-Attacks: A major factor in the delay of claim processing and,reporting in 2024 was the Change Healthcare cyber-attack, which caused massive backlogs for Medicare Administrative Contractors (MACs).

Government Shutdowns/Funding Gaps: Temporary holds were placed on certain Medicare claims due to budgetary and legislative gaps in late 2025.

Reduced Frequency of Mailings: While not a complete stop, Medicare shifted from quarterly to every-4-month (120 days) mailing of paper Medicare Summary Notices (MSNs) for some beneficiaries.

Shift to Electronic (eMSN): Medicare is encouraging a transition to electronic MSNs. If a user signs up for electronic notices, they may not receive paper copies, and the online portal might experience lag in showing those specific records. 

For the most up-to-date information, beneficiaries are advised to use the Medicare.gov portal directly, as third-party apps may not always have the latest data, or to contact Medicare at 1-800-MEDICARE if claims are not appearing.

https://www.medicare.gov/providers-services/claims-appeals-complaints/claims/check-status

In closing . . .

I hope you learned something from this topic. Many of my prospective existing clients ask questions like these so I decided to mix up the newsletter format again.

My goal is to educate you about your health and Medicare and do it in a way that is informative while explaining something complex in everyday terms.

On another note, my first round of cataract surgery in my right eye was successfully completed on 2/10/2025. My post-operative appointment on 2/11/2026 revealed my vision in the corrected eye is 20/20. No more followup required unless things change. The daily eyedrop regimen will continue for 6 weeks.

Feel free to share this newsletter with your friends. Call or email bob.vineyard@gmail.com if you have questions.

Bob & Rachel