Colonoscopy screening is an important preventive procedure that can detect colorectal cancer early when treatment is most effective. Medicare provides coverage for colonoscopies, but there are some specifics on how often Medicare will cover the procedure and whether you will have any out-of-pocket costs. Let’s break down the details on Medicare’s colonoscopy coverage.
What is a Colonoscopy?
A colonoscopy is a screening procedure used to check for abnormalities or disease in the large intestine (colon) and rectum. During a colonoscopy, a long, flexible tube called a colonoscope is inserted into the rectum. The colonoscope has a tiny video camera and light at the end, allowing the doctor to view the inside of the entire colon on a video monitor.
If any polyps or other abnormal tissue are found, the doctor can remove them through the colonoscope and send them for analysis. Removing polyps during a colonoscopy can prevent colorectal cancer from developing. A colonoscopy also allows the doctor to take a biopsy of any suspicious areas.
Who Should Get Colonoscopy Screening?
The United States Preventive Services Task Force recommends that adults age 50-75 get screened for colorectal cancer. There are several different screening test options, including:
- Colonoscopy – every 10 years
- Fecal occult blood test – every year
- Flexible sigmoidoscopy – every 5 years
- CT colonography – every 5 years
Colonoscopy is considered the “gold standard” for colorectal cancer screening because of its ability to view the entire colon and remove polyps before they become cancerous.
People at high risk for colorectal cancer may start screening earlier and be screened more frequently. Those at increased risk include people who:
- Have a personal history of colorectal cancer or polyps
- Have a family history of colorectal cancer
- Have inflammatory bowel disease (Crohn’s or ulcerative colitis)
- Have certain inherited syndromes such as familial adenomatous polyposis (FAP) or Lynch syndrome
Does Medicare Cover Colonoscopy Screening?
Yes, Original Medicare provides coverage for colonoscopy screening starting at age 50 for people at average risk, or earlier for those at high risk. This preventive screening is covered under Medicare Part B.
For a screening colonoscopy, Medicare Part B covers the full cost of the procedure once every 120 months (10 years) when your doctor accepts assignment. This means you pay nothing for the procedure if your doctor agrees to accept Medicare’s approved amount as full payment.
Medicare also covers the cost of the bowel prep kit, anesthesia services during the procedure, and any pathology exams on tissue samples taken during the colonoscopy.
When is a Colonoscopy Procedure Considered Diagnostic Rather than Screening?
A colonoscopy transitions from a screening exam to a diagnostic exam if your doctor finds and removes a polyp or performs a biopsy during the procedure. Removing polyps or taking a tissue sample cannot be predicted in advance, so you can’t know if your colonoscopy will end up being diagnostic until after it’s done.
Does Medicare Cover Diagnostic Colonoscopies?
Yes, Medicare will cover a colonoscopy, but the coverage is different than for screening colonoscopies:
- For a diagnostic colonoscopy, you pay 20% of the Medicare-approved amount after you’ve met your Part B deductible for the year.
- If your doctor takes biopsies or removes a polyp or other tissue during a screening colonoscopy, Medicare will cover the procedure but you may have to pay coinsurance.
- Medicare also covers repeat colonoscopies at shorter intervals when needed for follow-up after the removal of polyps or cancerous lesions.
The frequency of coverage for diagnostic colonoscopies depends on your individual risk and the results found during the procedure. Medicare covers them more often for high risk individuals when medically necessary.
How Often Does Medicare Cover Colorectal Cancer Screening?
- Screening colonoscopy – Once every 120 months (10 years), or every 24 months (2 years) if you’re at high risk
- Diagnostic colonoscopy – As often as medically necessary; no minimum interval
If you get a screening colonoscopy that turns into a diagnostic colonoscopy, Medicare insurance plan will cover your next colonoscopy in about 7 years as long as you don’t have another diagnostic colonoscopy in between.
Does Medicare Cover the Bowel Prep?
Yes, Original Medicare covers the bowel preparation (bowel prep kit) needed before a colonoscopy, up to certain limits. This is covered as part of the procedure itself.
If your doctor prescribes a self-administered bowel prep kit, you can get it from a pharmacy with a prescription and Medicare Part B should cover the cost. Bowel prep kits given to you at your doctor’s office are also covered.
Do Medicare Advantage Plans Cover Colonoscopies?
Medicare Advantage Plans must cover all services covered by Original Medicare, including colonoscopy screening. Many Medicare Advantage Plans also cover additional preventive services like dental cleanings and vision exams that aren’t covered by Original Medicare.
Check your plan documents or call your Medicare Advantage Plan directly to confirm details on colonoscopy coverage, network providers, and costs. Your out-of-pocket costs may be different under a Medicare Advantage Plan compared to Original Medicare.
For example, your plan may have a lower or no copayment for a preventive screening colonoscopy. But you may have higher copays or coinsurance for a diagnostic colonoscopy than you would under Original Medicare.
Does Medicare Cover Anesthesia for a Colon Cancer Screening?
Yes, Medicare Part B covers anesthesia services for colonoscopies performed in a hospital outpatient setting or ambulatory surgical center. Anesthesia is typically given intravenously to keep you comfortable during the procedure.
You will pay 20% of the Medicare-approved amount for the anesthesia after meeting your yearly Part B deductible. This coinsurance applies whether your colonoscopy is a screening or diagnostic procedure.
Will a Medicare Supplement Policy Help Cover The Cost of a Colonoscopy?
Having a Medicare Supplement (Medigap) policy can help cover your share of the costs for colonoscopies and other medical services. Medigap Plans pay for coinsurance, copayments, and deductibles – some plans pay the Part B deductible.
A Medigap policy gives you predictable out-of-pocket costs for services covered by Medicare Part A and Part B. This can be valuable if your screening colonoscopy transitions to a diagnostic colonoscopy with coinsurance.
It’s important to note that Medigap policies only cover services also covered by Medicare. They do not provide additional coverage for services that Medicare does not cover.
Finding a Doctor Who Accepts Medicare Coverage for Colonoscopies
When choosing a doctor for your colonoscopy, make sure they accept assignment from Medicare for the procedure. This means they accept Medicare’s approved amount as full payment and won’t bill you above that amount.
You can ask doctors in advance if they accept assignment, or search for ones who do on Medicare.gov. Doctors who don’t accept assignment may charge up to 15% over Medicare’s approved amount. This excess charge would be your responsibility.
Also check that the doctor participates with your Medicare Advantage Plan if you have one. Your costs will usually be lower when using in-network providers.
Getting screened for colorectal cancer with a colonoscopy can literally save your life. Thankfully, Original Medicare and Medicare Advantage Plans provide coverage for both preventive and diagnostic colonoscopy procedures.
Understanding Medicare’s colonoscopy coverage rules allows you to take advantage of these benefits and get screened when recommended by your doctor. Talk to your doctor about your personal risk factors and the appropriate colonoscopy screening schedule for your situation.
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What is the difference between a screening and diagnostic colonoscopy?
A screening colonoscopy is done to check for signs of cancer or other health issues when you have no symptoms. If a polyp or growth is found and removed during the procedure, it becomes a diagnostic colonoscopy.
How often does Original Medicare cover colonoscopy screenings?
Original Medicare covers screening colonoscopies once every 120 months (10 years) for people at average risk of colorectal cancer. It may be covered more often for those with a personal or family history of colon cancer or polyps.
Will my Medicare Advantage Plan cover colonoscopies?
Many Medicare Advantage Plans also cover colonoscopies as a preventive service. Be sure to check with your specific plan to understand your coverage and any costs.
What is the cost for a screening colonoscopy under Medicare?
Medicare Part B covers screening colonoscopies with no out-of-pocket costs for beneficiaries. This includes the procedure and anesthesia during the colonoscopy. You will pay nothing if your health care provider accepts assignment.
How often does Medicare cover colonoscopy screenings if polyps are found?
If a polyp is found and removed during a colonoscopy (making it diagnostic), Medicare will cover colonoscopies more frequently, such as every 2 years, depending on the number, size and type of polyps found.
What is the difference between screening and diagnostic coverage under Medicare?
Medicare covers screening colonoscopies with no out-of-pocket costs, but for diagnostic colonoscopies Medicare pays 80% and you pay 20% after meeting the Part B deductible. A screening colonoscopy finds and removes polyps, while a diagnostic colonoscopy is done to evaluate symptoms.
Does Medicare cover the cost of anesthesia for a colonoscopy?
Yes, Original Medicare Part B covers anesthesia administered in an outpatient hospital setting during a screening or diagnostic colonoscopy. There is no coinsurance or copayment required for beneficiaries.
What is the screening schedule for colon cancer under Medicare?
Medicare covers colorectal cancer screening tests, including screening colonoscopies, every 120 months (10 years) for averaged-risk individuals ages 45 and older. It may be more frequent depending on personal risk factors.
Do Medicare Supplement Plans (Medigap) cover colonoscopies?
Medigap Plans cover some costs that Original Medicare does not cover, including coinsurance or copayments for Medicare-covered services. This means Medigap Plan G covers 20% of Medicare-approved amounts for diagnostic colonoscopies after Part B deductible.
Will I have to pay anything if I get a preventative colonoscopy screening?
No, if you are enrolled in Original Medicare and your provider accepts Medicare’s approved amount as full payment, you will pay nothing out of pocket for a screening colonoscopy if no polyps are removed. Medicare covers the full cost as a preventive service.