Is Colonoscopy Screening Covered by Medicare?

September 24, 2023•10 min read

A colonoscopy is a medical procedure that allows a doctor to examine the inside of your colon (large intestine) for signs of colorectal cancer or other problems. A colonoscopy can also be used to remove polyps (abnormal growths) or other tissue samples for further testing. A colonoscopy is one of the most effective ways to prevent and detect colon cancer, which is the third most common cancer and the second leading cause of cancer death in the United States¹.

If you have Medicare, you may wonder if Medicare covers the test of a colonoscopy and how much they cost. The answer depends on whether the colonoscopy is done for screening or diagnostic purposes, and what type of Medicare Plan you have. In this article, we will explain the difference between screening and diagnostic colonoscopies, how can Medicare cover a colonoscopy, and what you may have to pay out of pocket.

What is a Screening Colonoscopy?

A screening colonoscopy is a colonoscopy that is done when you have no symptoms or history of colorectal cancer or polyps. The purpose of a screening colonoscopy is to check for any signs of colon cancer or precancerous polyps before they cause any problems. A screening colonoscopy is considered a preventive service, which means it can help prevent or delay the onset of a disease.

Does Medicare Cover Colonoscopy Screening?

Yes, Medicare covers screening colonoscopies as part of its preventive care benefits. Medicare (Part A and Medicare Part B) provides coverage for the full cost of a screening colonoscopy once every 10 years or every 120 months if you are age 50 or older, or once every 24 months if you're at high risk for developing colorectal cancer. You are considered at high risk if you have any of the following:

· A personal history of colorectal cancer or polyps

· A family history of colon cancer or polyps

· A genetic syndrome that increases your risk of colorectal cancer, such as familial adenomatous polyposis (FAP) or Lynch syndrome

· A history of inflammatory bowel disease, such as ulcerative colitis or Crohn's disease

If you have Original Medicare, you do not have to pay anything for a screening colonoscopy as long as your health care provider accepts assignment from Medicare. This means that your provider agrees to accept the Medicare-approved amount as full payment for the service. You also do not have to pay the Part B deductible for a screening colonoscopy.

However, if your provider finds and removes a polyp or other tissue during the screening colonoscopy, the procedure becomes a diagnostic colonoscopy. In that case, you may have to pay 20% of the Medicare-approved amount for your provider's services and the Part B deductible. You may also have to pay a coinsurance amount if the procedure is done in a hospital outpatient setting or an ambulatory surgical center.

If you have a Medicare Advantage Plan (Part C), your plan must cover at least the same benefits as Original Medicare for screening colonoscopies. However, your plan may have different rules, costs, and restrictions for how and where you get the service. For example, your plan may require prior authorization, referrals, or network providers for a screening colonoscopy. You should check with your plan before getting a screening colonoscopy to find out what your plan covers and what you may have to pay.

What is a Diagnostic Colonoscopy Procedure?

A diagnostic colonoscopy is a colonoscopy that is done when you have symptoms or history of colorectal cancer or polyps. The purpose of a diagnostic colonoscopy is to find out the cause of your symptoms or to monitor your condition after treatment. A diagnostic colonoscopy is considered a medical service, which means it can help treat or manage a disease.

Does Medicare Advantage Plans Cover Colonoscopies?

Yes, Medicare covers diagnostic colonoscopies as part of its medical care benefits. If you have Original Medicare, Medicare will cover 80% of the Medicare-approved amount for your provider's services after you pay the Part B deductible. You will be responsible for paying the remaining 20% coinsurance amount. You may also have to pay a coinsurance amount if the procedure is done in a hospital outpatient setting or an ambulatory surgical center.

If you have a Medicare Advantage Plan, your plan must cover at least the same benefits as Original Medicare for diagnostic colonoscopies. However, your plan may have different rules, costs, and restrictions for how and where you get the service. For example, your plan may require prior authorization, referrals, or network providers for a diagnostic colonoscopy coverage. You should check with your plan before getting a diagnostic colonoscopy to find out what your plan covers and what you may have to pay.

How Much Does a Colonoscopy Cost?

The full cost of a colonoscopy can vary depending on several factors, such as:

· The type of colonoscopy ( as a screening test or considered diagnostic)

· The type of Medicare Plan you have (Original Medicare or Medicare Advantage)

· The type of provider you see (in-network or out-of-network)

· The type of facility where you get the service (hospital, outpatient center, or doctor's office)

· The type of anesthesia you receive (conscious sedation or general anesthesia)

· The type of tissue samples or polyps that are removed (if any)

According to a 2016 study, the average cost of a colonoscopy in the United States was $1,811². However, this amount does not include the cost of anesthesia, which can add another $500 to $1,000 to the total cost³. The cost of a colonoscopy can also vary by state, with some states having higher or lower prices than the national average².

If you have Medicare, your out-of-pocket cost for a colonoscopy will depend on whether it is a screening or diagnostic colonoscopy, and what type of Medicare Plan you have. As mentioned above, if you have Original Medicare, you do not have to pay anything for a screening colonoscopy as long as your provider accepts assignment from Medicare and does not find and remove any polyps or tissue. However, if your provider finds and removes a polyp or tissue during the screening colonoscopy, you may have to pay 20% of the Medicare-approved amount for your provider's services and the Part B deductible. You may also have to pay a coinsurance amount if the procedure is done in a hospital outpatient setting or an ambulatory surgical center.

If you have a diagnostic colonoscopy with Original Medicare, you will have to pay 20% of the Medicare-approved amount for your provider's services and the Part B deductible. You may also have to pay a coinsurance amount if the procedure is done in a hospital outpatient setting or an ambulatory surgical center.

If you have a Medicare Advantage Plan, your out-of-pocket cost for a colonoscopy will depend on your plan's rules, costs, and restrictions. You should check with your plan before getting a colonoscopy to find out what your plan covers and what you may have to pay.

How Can You Lower Your Colorectal Cancer Screening Cost?

There are some ways that you can lower your cost for a colonoscopy if you have Medicare. These include:

· Choosing a provider that accepts assignment from Medicare coverage. This means that your provider agrees to accept the Medicare-approved amount as full payment for the service and will not charge you more than that amount. You can find providers that accept assignments from Medicare by using the [Physician Compare] tool on [Medicare.gov] or by calling 1-800-MEDICARE (1-800-633-4227).

· Choosing a facility that is in-network with your Medicare Advantage Plan. This means that your plan has an agreement with the facility to provide services at a lower cost. You can find facilities that are in-network with your plan by using the [Medicare Plan Finder] tool on [Medicare.gov] or by contacting your plan directly.

· Choosing a facility that is certified by Medicare. This means that the facility meets certain quality and safety standards set by Medicare. You can find facilities that are certified by Medicare by using the [Hospital Compare] tool on [Medicare.gov] or by calling 1-800-MEDICARE (1-800-633-4227).

· Choosing conscious sedation over general anesthesia. This means that you will be awake but relaxed during the procedure and will not feel any pain. Conscious sedation is usually cheaper than general anesthesia and may be covered by Medicare as part of the colonoscopy service. However, conscious sedation may not be suitable for everyone, especially if you have certain medical conditions or allergies. You should talk to your provider about the best option for you.

· Choosing a screening colonoscopy over a diagnostic colonoscopy. This means that you will get a colonoscopy when you have no symptoms or history of colorectal cancer or polyps. A screening colonoscopy is usually cheaper than a diagnostic colonoscopy and may be covered by Medicare at no cost to you. However, a colon cancer screening test may not be appropriate for everyone, especially if you have symptoms or risk factors for colorectal cancer. You should talk to your provider about the best option for you.

Conclusion

A colonoscopy is an important health service that can help prevent and detect colorectal cancer, which is the third most common cancer and the second leading cause of cancer death in the United States. If you have Medicare, you may be eligible for coverage for colonoscopy screenings or diagnostic colonoscopies depending on your age, health condition, and type of Medicare Plan. However, your out-of-pocket cost for a colonoscopy may vary depending on several factors, such as the type of provider, facility, anesthesia, and tissue samples or polyps involved. You can lower your cost for a colonoscopy by choosing providers and facilities that accept assignment

FAQ

What is a flexible sigmoidoscopy?

A flexible sigmoidoscopy is a screening test that allows a doctor to examine the lower part of the colon and rectum for signs of cancer or precancerous polyps. During the exam, a short, lighted, flexible tube (called a sigmoidoscope) is inserted into the rectum and lower colon. A doctor is able to examine the inner lining of these areas visually.

Does Medicare help pay for diagnostic colonoscopies?

Coverage for diagnostic colonoscopiers is viable if a colonoscopy originally performed as a screening finds an issue requiring diagnosis, Medicare pays most of the costs of the diagnostic procedure after meeting the yearly deductible.

Does Medicare cover colonoscopy prep costs?

Original Medicare does not cover over-the-counter colonoscopy prep kits needed for successful screening. Some Medicare Supplement or Medicare Advantage Plans may include prep coverage.

How often can I get a screening colonoscopy?

Medicare insurance plan will cover one screening colonoscopy every two years if you are at higher than average risk for colon cancer due to factors like a family history.

What is considered high risk for colon cancer?

Factors like having a personal history of adenomatous polyps or colorectal cancer or having a family history of the disease put someone at higher than average risk. Medicare may allow earlier or more frequent screening in high risk individuals based on a doctor's recommendation.

Do Medicare Advantage Plans provide the same coverage?

Many Medicare Advantage Plans also cover screening colonoscopies as long as you use in-network providers. You generally won’t have any out-of-pocket costs for Medicare-covered preventive screenings.

What is a colonoscopy?

Colonoscopy is a preventive service or medical test that allows a doctor to examine the inner lining of the entire large intestine, which is part of the digestive system.

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