Colonoscopies are a common screening procedure used to detect colorectal cancer. Many people wonder if colonoscopies are covered by Medicare. The answer is yes – but the coverage depends on whether it is a preventive screening colonoscopy or a diagnostic colonoscopy.
What is a Colonoscopy?
A colonoscopy is a procedure that allows a doctor to examine the entire length of the colon and rectum using a colonoscope. A colonoscope is a flexible tube with a light and camera at the end that provides a video image on a screen. This test is used to screen for colon polyps or colorectal cancer.
During a colonoscopy, the doctor is able to see any abnormalities in the colon and rectum. If any polyps are found, the doctor can remove them right then and there. A polyp is a small clump of cells that forms on the lining of the colon. Some polyps may eventually turn cancerous if they are not removed. When polyps are found early and removed, it can prevent colorectal cancer.
Does Medicare Cover Colonoscopy Screening
Medicare Part B covers screening colonoscopies to check for colorectal cancer once every 120 months (10 years) if you are age 50 or older with no signs or symptoms and no personal history of colorectal cancer or polyps.
For people at high risk for colorectal cancer, Medicare covers screening colonoscopies once every 24 months. You are at high risk if you have:
- A personal history of colorectal cancer or certain types of polyps
- A family history of colorectal cancer
- A personal history of inflammatory bowel disease
- An inherited colorectal cancer syndrome
With Medicare Part B, you pay nothing for the screening colonoscopy if your doctor accepts assignment. Medicare covers the colonoscopy 100% when it is used as a preventive screening test. This includes the removal of any polyps during the screening colonoscopy.
However, you may have to pay a copayment for the doctor’s services on the day of the procedure. The Part B deductible does not apply for a preventive colonoscopy screening.
If your doctor performs anesthesia services during the colonoscopy, Medicare Part B also covers those under the preventive benefit. You typically pay nothing for the anesthesia services.
Medicare Coverage for Diagnostic Colonoscopies
A colonoscopy transitions from a preventive screening and becomes a diagnostic colonoscopy procedure when the doctor finds and removes a polyp or other tissue during the colonoscopy.
When this happens, Medicare covers the colonoscopy as a diagnostic test under Part B rather than for screening. This means:
- You pay 20% of the Medicare-approved amount for the doctor’s services after you meet the yearly Part B deductible.
- You pay a copayment for the procedure at a hospital outpatient setting.
- You pay 20% of the Medicare-approved amount for the cost of anesthesia services.
Medicare covers diagnostic colonoscopies when they are medically necessary. Some reasons Medicare may cover a diagnostic colonoscopy include:
- Following up on problems found during a previous colonoscopy or other colorectal cancer screening test
- Evaluating changes in bowel habits, unexplained weight loss, bleeding from the rectum, or other symptoms
- Monitoring your condition if you have a personal history of colorectal cancer or polyps
- Surveillance following surgery or treatment for colorectal cancer or polyps
Talk to your doctor about whether your upcoming colonoscopy would be considered preventive screening or diagnostic so you know what to expect with Medicare cost coverage.
What is the Cost of a Colonoscopy Procedure?
The cost of a colonoscopy can vary depending on factors like your health insurance coverage and whether polyps are found and removed. Here are some typical colonoscopy cost ranges:
- Without insurance: The average colonoscopy procedure ranges from $600-1,500. This covers the physician’s fee for performing the procedure, facility fees and anesthesia administration.
- With private insurance: Most private health plans cover routine colonoscopies as a preventive service at little to no out-of-pocket cost. This is because preventing colorectal cancer is considered high value. You may have a copay of $0-500 depending on your plan.
- With Medicare: Routine screening colonoscopies are covered by Medicare at no additional cost beyond your Part B premiums. However, if polyps are found and removed during the test, you may have to meet your yearly Part B deductible of $233 in 2023 first.
- Out of pocket max: Your insurance’s annual out-of-pocket maximum protects you from costs over a set amount, usually $3,000-$6,000 for individuals. Colonoscopy claims will apply to this limit if not fully covered.
- Additional costs: Factors like biopsies, polyp removal, anesthesia services from a separate provider and pathology lab fees can potentially bring the total to $1,500-$3,000 depending on the complexity. But most insurance plans cover these services too.
Medicare Coverage for Colon Cancer Screenings
Medicare covers several options for colorectal cancer screening, not just colonoscopies.
Some other colorectal cancer screening tests covered by Medicare include:
- Flexible sigmoidoscopy – This procedure uses a sigmoidoscope to examine the rectum and lower part of the colon. Medicare covers this screening test once every 120 months, or once every 48 months if you are at high risk for colorectal cancer.
- Fecal occult blood test – This lab test detects blood in your stool, which can indicate colorectal cancer or polyps. Medicare covers this test once every 12 months if you are age 50 or older.
- Cologuard DNA testing – This test screens for abnormal DNA and blood in the stool. Medicare covers this screening once every 3 years for people ages 50-85 without symptoms.
- CT colonography or virtual colonoscopy – This imaging procedure uses X-rays and computers to create images of the colon from outside the body. Medicare covers it once every five years for people ages 50-75.
Talk to your doctor about which colorectal cancer screening option may be right for your situation and health history. The frequency of screening covered by Medicare varies depending on the test.
Medicare Advantage Plans Cover
Medicare Advantage Plans, sometimes called Part C, must cover all medically necessary colonoscopies just like Original Medicare. This includes both preventive and diagnostic colonoscopies.
With Medicare Advantage Plans, copays, coinsurance, and deductibles for colonoscopies will depend on the plan. Many Medicare Advantage Plans also offer extra benefits like routine colonoscopies for people under age 50 or for higher than normal risk patients.
Always check details of the plan for cost sharing and extra coverage perks for colonoscopies and other colorectal cancer screenings tests.
Medicare Supplement (Medigap) Coverage for Colonoscopy Screenings
Original Medicare does not cover the full cost of colonoscopies in all cases. There can be copays for the procedure and doctor services. Medicare Supplement Insurance plans help pay some costs that Original Medicare does not cover.
Different Medigap policies cover different benefits. Several Medigap Plans cover the Medicare Part B coinsurance or copayment for colonoscopies. So you may want to consider a Medicare Supplement Plan if you are undergoing frequent diagnostic colonoscopies and related services.
That covers the key points on whether colonoscopies are covered by Medicare. In summary:
- Medicare Part B covers one preventive screening colonoscopy every 10 years if you are age 50+ and don’t have symptoms. You typically pay nothing if your provider accepts Medicare assignment.
- Diagnostic colonoscopies are also covered but often involve cost sharing for Medicare beneficiaries.
- Medicare covers other colorectal cancer screening tests besides colonoscopies, each with their own frequency limits.
- Medicare Advantage Plans must offer the same colonoscopy coverage as Original Medicare but can have different cost sharing.
- Medigap policies may help pay your share of Medicare costs for colonoscopies.
Talk to your doctor about your colorectal cancer screening options and exactly what Medicare will cover. Understanding the costs for different colonoscopy scenarios can help you plan financially.
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Does Medicare cover a colonoscopy?
Original Medicare covers screening colonoscopies once every ten years for average-risk individuals to detect colorectal cancer. This includes the procedure and anesthesia.
What does Medicare pay for?
Medicare pays 100% for a routine screening colonoscopy every ten years for beneficiaries at average risk of colorectal cancer. Medicare Supplement Plans may help cover costs Medicare doesn’t.
Will I have to pay for a colonoscopy?
If you have regular Medicare, have no risk factors, and it’s been at least ten years since your last screening colonoscopy, you shouldn’t pay anything out of pocket for the screening test.
What if a polyp is found?
If the doctor finds and removes a polyp during a screening colonoscopy, Medicare may consider it diagnostic and you could be responsible for deductibles or coinsurance.
How often is a colonoscopy covered?
Medicare covers routine screening colonoscopies once every ten years for average-risk beneficiaries. High-risk individuals may be eligible for colonoscopies every two years according to their personal health history and risk factors.