Colorectal cancer is a common illness, affecting approximately 1 in 23 men and 1 in 25 women in the United States. It can be fatal if left undiagnosed until its late stages but is highly preventable or treatable when caught early. A colonoscopy is considered the gold standard for diagnosing colorectal cancer and is recommended every 10 years starting at age 45. Earlier or more frequent colonoscopies may be needed based on your personal risk factors and history.
If you’re on Medicare, you might have several questions. Does Medicare cover colonoscopies? How often does Medicare pay for a colonoscopy? Does Medicare cover a colonoscopy after age 70? Let’s dig into the details of exact coverages and costs.
Does Medicare pay for a colonoscopy?
The simple answer is yes. Under the Patient Protection and Affordable Care Act of 2010 (Obamacare), a colonoscopy is an essential benefit. This means that Medicare, as well as private insurers, must cover the cost at 100% starting at age 45.
In reality, though, it’s not as simple as it might seem. To understand why, we’ll need to review exactly how Medicare works.
Medicare is a government-sponsored health insurance program offered to those ages 65 and above, as well as people with qualifying disabilities, that covers many healthcare costs. But there are four separate parts, and only Parts A and B are included in the original Medicare.
Medicare Part A, or hospitalization insurance, pays for medically required stays in the hospital, as well as certain other services such as hospice. This part is free to everyone starting at age 65 (or when you become eligible due to disability), provided you worked and paid Medicare taxes.
Medicare Part B is for general medical services. You will become eligible for Part B at the same time as Part A, but you must enroll and pay a low monthly premium. There is also a small deductible. This is the part that covers doctor visits, imaging tests, screenings, and similar medically necessary services.
Taken together, Medicare Parts A and B comprise the original Medicare. Under these benefits, you are entitled to no-cost screening colonoscopies every 10 years if you are at average risk, or every two years if you are at high risk for colorectal cancer.
But many people have polyps in their colons. While these polyps are often not cancerous, they could develop into cancer over time. Therefore, doctors will often remove them as part of the colonoscopy.
If you have polyps removed during your Medicare colonoscopy, you will be responsible for paying 15% of the doctor’s charges, as well as 15% of the hospital charges (if performed in a hospital outpatient setting).
Medicare Part C, or Medicare Advantage, and Medicare Part D (prescription drug coverage) can help cover healthcare costs that are not covered by original Medicare. These optional products are sold by private insurers such as BCBS of Kansas, and offer additional coverages for more complete wraparound health protection. Many Medicare Advantage plans include Part D coverage, so you might not need a separate prescription drug plan. In general, Medicare Parts C and D provide more robust coverage while also capping your annual out-of-pocket costs.
Depending on the specifics of your Part C plan, you may be eligible for more frequent colonoscopies than original Medicare allows. You may also pay less out of pocket if tissue is removed, or the procedure is performed in a hospital.
Does Medicare cover a colonoscopy after a positive Cologuard test?
Cologuard is a newer technology that allows you to screen for colon cancer without undergoing a full colonoscopy. Designed for those at average risk, the procedure involves taking your own stool sample at home and sending it to a designated lab for analysis. Negative results are considered valid for three years. But if you test positive, you will need a colonoscopy to determine whether you actually have colorectal cancer or some other illness, or whether it was a false positive.
Medicare typically covers the costs of Cologuard. But after a positive Cologuard test, Medicare considers a colonoscopy diagnostic rather than screening. This means that standard Medicare copays will apply.
Medicare Advantage typically provides more complete coverage. Depending on your plan, this may include a colonoscopy following a positive Cologuard test.
How much does a colonoscopy cost with Medicare?
It depends. If you are receiving a screening colonoscopy according to Medicare guidelines, you will not have to pay anything out of pocket.
But if polyps or other tissue samples are removed, or if the colonoscopy is otherwise considered diagnostic rather than screening, copays and possibly your deductible will apply. Note that these copays will apply not only to the colonoscopy itself but also to hospital charges, as well as any medications, such as anesthesia, that are provided during the procedure.
If you are getting a colonoscopy outside of Medicare guidelines, original Medicare may not pay anything at all. However, if you have a Part C plan, you might be eligible for coverage.
What is a Medicare screening vs. diagnostic colonoscopy?
Determining whether a colonoscopy is considered screening or diagnostic under Medicare rules can be a bit confusing. But in general, a colonoscopy turns from screening to diagnostic if any tissue is removed during the colonoscopy or if the colonoscopy follows a positive Cologuard or other screening test.
At what age does Medicare stop paying for a colonoscopy?
One of the biggest questions that many people have is, “Does Medicare cover a colonoscopy after age 75?” This is likely because general screening guidelines recommend regular colonoscopy screenings from age 45 through 75. Because colorectal cancer is often slow growing, and colonoscopies carry rare, but nonetheless real, risks, some experts believe that colonoscopies are not necessary after age 75. Others believe the age cutoff should be 85. Your doctor will help you decide if a colonoscopy is right for you.
Regardless of prevailing medical opinions, Medicare does not set an upper age limit on colonoscopies. If your doctor believes that they are appropriate for your unique situation, you will continue to receive coverage for screening colonoscopies every 10 years if you are at average risk, or every two years if you are at high risk, for the rest of your life. Standard coverage will also continue to apply for diagnostic colonoscopies, with you taking responsibility for your copays and deductible.
Do I need a referral for a colonoscopy on Medicare?
Generally, no. While many private insurers require a referral from your primary doctor in order to see a specialist, Medicare does not. However, you will need to make sure that the physician you choose accepts Medicare assignment, or you might have to pay out of pocket. If you have a Medicare Advantage plan, you will need to make sure that the doctor is part of that specific plan’s network.
Does Medicare require preauthorization for a colonoscopy?
No. You do not need to obtain a preauthorization for Medicare to pay for a colonoscopy. However, if you choose Cologuard or another type of colorectal screening test, preauthorization may be required. In addition, rules can change at any time. Always talk to your doctor’s billing office before scheduling any procedure to make sure you are following the latest guidance.
Are there other charges associated with a colonoscopy, and does Medicare cover those?
Costs associated with a colonoscopy include the doctor’s services, hospital or other facility fees, and medications such as anesthesia. All these charges are covered at 100% for screening colonoscopies, but copays and possibly your deductible will apply if the colonoscopy is deemed diagnostic.
It’s also important to note that a colonoscopy may be the first step in a long medical journey. If your colonoscopy is clear, or if noncancerous polyps are removed, that is typically the end of it. But colonoscopies can diagnose not only cancer, but also a variety of diseases such as Crohn’s or ulcerative colitis. If any illness is found, you and your doctor will work together to determine a treatment plan.
While original Medicare covers many of the costs of treating illnesses, including cancer, its coverage is not necessarily complete. Various drugs and other therapies may not be covered, along with things like wigs for those receiving chemotherapy and radiation treatment. And there is no cap on out-of-pocket expenses with original Medicare. With treatments for some diseases running into hundreds of thousands of dollars, your share of the expenses could be significant.
Medicare Parts C and D provide more robust coverage than original Medicare. They tend to cover therapies that are not covered under original Medicare, and each plan has an annual out-of-pocket limit. Once you reach that limit, your treatment costs are covered at 100% for the rest of the year.
Colorectal cancer is a scary disease, though early detection and treatment lead to high survivability rates. The last thing you need is to worry about how you will pay for testing and treatment. To learn more about how a Medicare Part C (Medicare Advantage) plan can help plug the gaps in original Medicare coverage, call Blue Cross and Blue Shield of Kansas today at 866-627-6705.