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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What Is a Colonoscopy?
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.
Does Medicare Cover Colonoscopy?
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.
What Does Medicare Pay for a Colonoscopy?
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.See AlsoHow much do endoscopies cost?
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.
At What Age Does Medicare Stop Paying for a Colonoscopy?
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.
What Is the Medicare Co-pay for a Colonoscopy?
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.
Learn More: Can Medigap Plan G Save You Money?
What Other Types of Colorectal Screening Tests Do Medicare Health Plans Cover?
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.(Video) Does Medicare Cover a Free Regular Colonoscopy? Georgia Medicare Plans
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.
FAQ: Medicare and Colonoscopies
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.
Conclusion: Take Advantage of Medicare ’s Colonoscopy Coverage
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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How much money does Medicare pay for a colonoscopy? ›
Colonoscopy is a preventive service covered by Part B. Medicare pays all costs, including the cost of anesthesia, if the doctor or other provider who does the procedure accepts Medicare assignment. You don't have a copay or coinsurance, and the Part B doesn't apply.At what age does Medicare stop paying for colonoscopy? ›
Does Medicare pay for a colonoscopy after age 75? Yes. Medicare will cover colonoscopy after age 75. There are no age requirements in order to receive coverage for this procedure.How can I reduce the cost of a colonoscopy? ›
- Financial aid. Many hospitals and clinics have financial aid programs that often offer discounts or interest-free payment plans. ...
- Colonoscopy assist programs. ...
- Medical loans. ...
- Medical credit card. ...
- Shop around.
The "Medicare loophole" happens when your routine colonoscopy screening detects medical issues. When that occurs, your test is no longer considered a screening and is no longer free. It then becomes a diagnostic procedure, and you're charged the 20% Medicare coinsurance.What is considered high risk for Medicare colonoscopy? ›
Characteristics of the High Risk Individual:
A family history of hereditary nonpolyposis colorectal cancer; A personal history of adenomatous polyps; A personal history of colorectal cancer; or. Inflammatory bowel disease, including Crohn's Disease, and ulcerative colitis.
If your doctor finds and removes a polyp or other tissue during the screening, the procedure becomes a diagnostic colonoscopy. Then you may have to pay Part B coinsurance, which is 20 percent of the Medicare-approved amount. But you still won't have to worry about your Part B deductible, which is $233 in 2022.At what age are colonoscopies unnecessary? ›
There's no upper age limit for colon cancer screening. But most medical organizations in the United States agree that the benefits of screening decline after age 75 for most people and there's little evidence to support continuing screening after age 85. Discuss colon cancer screening with your health care provider.How common are colon polyps in 70 year olds? ›
Colon polyps are extremely common among adults 50 years of age and older, occurring in over 40 percent of individuals who undergo screening colonoscopy.How often should a 65 year old have a colonoscopy? ›
Get your first screening at age 45. If you're at average risk, you should have a colonoscopy once each decade through age 75. If you're at a higher risk for colon cancer, your doctor may recommend a colonoscopy every five years instead.Is there a new alternative to a colonoscopy? ›
Virtual colonoscopy is a special X-ray examination of the colon using low dose computed tomography (CT). It is a less invasive procedure than a conventional colonoscopy. A radiologist reviews the images from the virtual colonoscopy to look for polyps on the inside of the colon that can sometimes turn into colon cancer.
Is there an alternative to a colonoscopy? ›
Colonoscopy is one method of screening for colorectal cancer. Other methods are also effective and available. Alternatives to colonoscopy include sigmoidoscopy, which is a less invasive form of colonoscopy, and noninvasive methods, such as stool sample testing.How much is a colonoscopy without insurance? ›
A colonoscopy is a procedure done by a doctor to determine irregularities in the colon. The out-of-pocket costs of a colonoscopy can range between $1,250 to $4,800.How can I reduce my Medicare costs? ›
- File a Medicare IRMAA Appeal. ...
- Pay Medicare Premiums with your HSA. ...
- Get Help Paying Medicare Premiums. ...
- Low-Income Subsidy. ...
- Medicare Advantage with Part B Premium Reduction. ...
- Deduct your Medicare Premiums from your Taxes. ...
- Grow Part-time Income to Pay Your Medicare Premiums.
“There are risks involved with colonoscopy, such as bleeding and perforation of the colon, and also risks involved with the preparation, especially in older people,” Dr. Umar said.Why are you forced to have Medicare? ›
Why Are You Forced Into Medicare? If you or your spouse worked for at least 10 years in a job where Medicare taxes were withheld (including self-employment where you paid your own self-employment taxes), you'll become automatically eligible for Medicare once you turn 65.How often should you have a colonoscopy if polyps are found? ›
In 1 to 7 years, depending on a variety of factors: The number, size and type of polyps removed; if you have a history of polyps in previous colonoscopy procedures; if you have certain genetic syndromes; or if you have a family history of colon cancer.Does Medicare require preauthorization for a colonoscopy? ›
Yes, Medicare requires prior authorization for a colonoscopy. Coverage will apply only if your physician authorizes a colonoscopy for the Medicare-approved amount. How much does a colonoscopy cost out of pocket?Is personal history of colon polyps considered a screening? ›
A family history but no personal history of colon polyps or colon cancer is sometimes considered surveillance and does not fall under screening benefits.What happens when they remove polyps during a colonoscopy? ›
After polyps are removed, you will need to return for an additional colonoscopy. There is a 25% to 30% chance that a repeat colonoscopy will find additional polyps. How soon you need to return for follow-up depends largely on the size of the polyps found in the first exam.How much does it cost to remove polyps during a colonoscopy? ›
|Units||Avg Cash price|
|Provider fee to scope and remove growth from colon Complex Standard||1||$315|
|Surgery center fee to scope and remove growth from colon Standard Standard||1||$635|
Does Medicare pay for CT scan of colon? ›
Most commercial insurance providers, Medicare and Medicare Advantage plans cover CTC as a diagnostic test. This is important especially if you have a failed colonoscopy or cannot undergo a colonoscopy due to medical reasons.Does Medicare Part D pay for colonoscopy prep? ›
If your physician orders a colonoscopy prep kit, your Medicare Part D prescription drug plan will likely provide coverage. However, each Medicare Part D plan provides different coverage. Thus, your plan may leave you responsible for a copayment or coinsurance when you receive the prep kit.Can you claim a colonoscopy on Medicare? ›
The good news is that you pay nothing for a screening colonoscopy if your doctor or other qualified health care provider accepts Medicare. Medicare Part B covers colonoscopy, but the Part B deductible doesn't apply to this procedure.Is a CT scan of the colon as good as a colonoscopy? ›
A traditional colonoscopy is the most widely known colorectal cancer screening procedure, but many patients are choosing a non-invasive CT (computerized tomography) Colonography instead. A CT Colonography doesn't require sedation and is just as accurate at detecting most precancerous polyps.Will Medicare pay for a colonoscopy after a positive cologuard? ›
For patients with traditional Medicare, a colonoscopy after a positive Cologuard result is still a screening colonoscopy based on updated Centers for Medicare & Medicaid Services regulations, effective January 1, 2023. Medicare does not apply cost sharing to screening colonoscopy.Is colonoscopy covered by Affordable Care Act? ›
The Affordable Care Act requires that insurance policies cover certain preventative services, such as colonoscopies, at no cost to the patient. However, the insurance industry has established strict guidelines for what defines a screening/preventative service.What are alternatives to colonoscopy? ›
A colonoscopy is not your only option for screening for colon cancer. Other screening methods are sigmoidoscopy, virtual colonoscopy, a fecal immunochemical test, a fecal occult blood test, or a stool DNA test.What is the most common complication after colonoscopy? ›
Bleeding is one of the most common complications of colonoscopy, accounting for 0.3-6.1% of cases[35,36].What are the new guidelines for colonoscopy? ›
- Colonoscopy every 10 years.
- CT colonography (virtual colonoscopy) every 5 years.
- Flexible sigmoidoscopy (FSIG) every 5 years.