Updated October 29, 2021
Reading time: 5 minutes
According to the American Cancer Society, colorectal cancer is one of the leading diagnoses and causes of death for cancer patients in the United States. It currently sits in the top five of the most common cancer diagnoses in the country. So what can you do if you are at high risk of getting colon cancer?
One way to properly catch and develop a treatment for this disease is to periodically get a colorectal cancer screening, also known as a screening colonoscopy.
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A colonoscopy is a procedure that allows doctors to get a picture-clear view of the rectum and colon. Using a camera inserted through the rectum, the examining doctor can look at the tissue, remove polyps, and perform a biopsy of abnormal tissue.
The results of a colonoscopy can help give you a solid idea about the health of your colon and act as an early indicator for more severe issues, like colorectal cancer.
Yes, Medicare covers colonoscopies! However, some Medicare beneficiaries get more extensive coverage than others (more on this below).
A colonoscopy can give you and your doctors all the information needed to develop a proper and beneficial treatment plan specific to you. As a valuable and covered medical procedure, there’s no reason not to get a screening.
Thanks to the Affordable Care Act, private insurers and Original Medicare must completely cover screening colonoscopies. Such screening services come at no cost to you, so long as your doctor or provider accepts the assignment. However, this Medicare coverage does come with a handful of significant caveats:
High Risk: If you are at increased risk for colorectal cancer, Medicare will cover one colonoscopy cost every 24 months. Those who have a family history of colorectal cancer, a history of colon polyps, or a history of inflammatory bowel disease / ulcerative colitis are at high risk.
Low to Average Risk: If you are at low risk for colorectal cancer, Medicare will cover colonoscopy every 120 months. However, if you have previously had a flexible sigmoidoscopy, Medicare will cover one colonoscopy every 48 months.
Polyps and Abnormal Tissue: If your doctor conducts a polyp removal or finds other tissue abnormalities during your colonoscopy, you may have to pay a 20 percent coinsurance of the Medicare -approved amount for your doctor’s services. You’ll also need to cover a co-payment if you receive the colonoscopy in a hospital setting (instead of an outpatient facility). In this situation, the Part B deductible does not apply.
Should your colonoscopy reveal any polyps or abnormal tissue, it’s necessary to consider various factors when calculating the procedure’s overall cost and other screening services. Such factors include:
Other Insurance Plans: If you’re enrolled in other insurance policies (through your spouse’s private insurance, for example), the healthcare coverage of those policies could affect the overall cost.
Doctors: The procedure and service costs can vary from doctor to doctor, whether or not they accept assignment.
Location: The type of facility in which you receive the colonoscopy can affect the overall cost. For example, if you receive a colonoscopy at an outpatient surgery center, it will likely cost less than if you receive it in the hospital.
Anesthesia: In some cases, patients can select to receive general anesthesia instead of conscious sedation to complete the procedure. If you prefer general anesthesia, the procedure’s cost may go up due to the anesthesiologist’s fees. Anesthesia is typically more of a factor for Medicare Part C/ Medicare Advantage plans, as doctors and anesthesia providers must be in-network to be eligible for coverage.
While Medicare offers either 80 percent or complete coverage for a colonoscopy, it is essential to note that your doctor may recommend further medical treatment that Medicare might not cover. They may also recommend screenings more often than Medicare can cover them.
According to the U.S. Preventive Services Task Force, individuals aged 50 or older should receive colonoscopies to gauge their colorectal health. If your family has a history of colorectal cancer or you have other cancer risk factors in play, you should start getting screening tests even sooner.
With that in mind, Medicare has no upper age requirement or restriction. There is no age at which Medicare health insurance will stop covering you for colonoscopies, provided that you are receiving them as often as your plan will allow.
Technically, there is no co-pay for a colonoscopy under Medicare. As stated previously, Medicare will cover the entire cost of a colonoscopy, so long as the procedure is preventative. If any polyps or abnormalities present themselves during the procedure, the procedure will become “diagnostic,” and you will be responsible for out-of- pocket costs equal to a 20 percent coinsurance.
In terms of co-payments, you would be responsible for a co-payment if your colonoscopy procedure is done in the hospital. If you have Medigap (Medicare Supplement Insurance), part or all of your copayment may be covered.
While a colonoscopy is a very effective way to gauge your colorectal health, there are several other screening tests that Medicare covers:
- Fecal Occult Blood Test (FOBT): This test takes a sample of your feces and checks for any evidence of blood. Under Medicare, you are covered for one FOBT test every 12 months, provided that you are over the age of 50. You will also need a referral from your doctor, physician assistant, nurse practitioner, or clinical nurse specialist.
- Stool DNA Test: This test is a more sensitive version of the FOBT test. Under Medicare, you are covered for one stool DNA test every three years, provided that you meet all of the following conditions:
You are between the ages of 50 and 85.
You have no symptoms of colorectal disease, such as blood in stool, lower gastrointestinal pain, or a positive FOBT.
You have no personal or family history of colorectal cancer, polyps, or inflammatory bowel disease.
Flexible Sigmoidoscopy: This test is similar to but less invasive than a colonoscopy. Under Medicare, you are covered for one flexible sigmoidoscopy every 48 months if you are over 50 years old and at high risk for colorectal cancer. If you are at low to average risk and have had a previous screening colonoscopy, you are covered for one flexible sigmoidoscopy every 120 months. If the flexible sigmoidoscopy results in a biopsy, you’ll be required to pay a co-payment or coinsurance.
Double-Contrast Barium Enema: This test uses a series of X-rays to visualize the colon from the outside. Provided that you are over 50 years of age and at high risk, your Medicare Part B will cover 80 percent of this test’s Medicare -approved costs, and you will be covered for one test every 24 months. If you are at low to average risk, Medicare will offer reimbursement for one test every 48 months.
Medicare Part B covers colonoscopies that are performed through outpatient services.
While the monthly premium for a Part B plan is $198 per month, Part B fully covers a colonoscopy. What’s more, you will not have to meet your Part B deductible for coverage of the colonoscopy costs to take effect.
It is important to note that Part B only covers colonoscopies in an outpatient surgery center. Suppose you have a colonoscopy in a hospital. In that case, Medicare will still cover the colonoscopy. Yet, you’ll always have to pay a hospital co-payment and a 20 percent coinsurance if a polyp or abnormal tissue biopsy occurs.
When it comes to other parts of Medicare, Part D plans do not cover colonoscopies themselves, but they might cover prescriptions for bowel preparation medication. This medication helps to clean out the colon before a colonoscopy procedure. It would be a good idea to check your Part D plan to see if it covers such medication.
Before requesting a colonoscopy, your doctor may need prior authorization from Medicare.
Generally, Medicare requires prior authorization for a colonoscopy before most Medicare Advantage plans begin to cover the procedure. This means that before your doctor can refer you to a gastroenterologist, they will need approval from Medicare.
While it’s hard to know offhand whether you are experiencing symptoms of colorectal cancer, you can rest assured that Medicare will either substantially or entirely cover the cost of a colonoscopy. Whether or not you have any personal or family history with colorectal disease, it’s always a great idea to get one if you are over 50. It can dramatically increase your peace of mind knowing your colon and rectum ’s health. Such information can help you and your doctor plot a suitable course of treatment that will undoubtedly benefit your health.
If you would like to get a colonoscopy and are not covered by Medicare, please contact your insurance company for more information. If you have completed Medicare enrollment, you can visit medicare.gov for more details regarding colorectal screening coverage.
And don’t forget that the Insurify Medicare comparison tool is always here to help you find the best Medicare plan at the best price. With just your ZIP code, you can uncover plan options and compare them side-by-side. Try it today!
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Originally from Los Angeles, California, Adrian Coto is a writer living in Brooklyn, New York. A graduate of the NYU Creative Writing MFA program, he's worked as a legal assistant, a law school administrator, and now as a copywriter and editor.Learn More