Does Medicare cover colonoscopy?
Yes. The Affordable Care Act (ACA) requires Medicare and private insurers to cover the costs of diagnostic tests for colorectal cancer, including colonoscopy. A colonoscopy is a vital health exam that can help prevent and treat different types of colon cancer by removing polyps or precancerous growths.
Medicare will cover a colonoscopy every 24 months for people at high risk of developing colorectal cancer and every 180 months for people who are not at high risk. There is no age requirement.
The United States Preventive Services Task Force recommends that people have a colonoscopy starting at age 50 and continuing until they are at least 75. If you have a family history of colon cancer or other risk factors for developing cancer, some doctors may recommend that you have one done earlier.
According to the Department of Health and Human Services, Medicare spent approximately $1.3 billion in reimbursements for colonoscopy in 2015.
What is a colonoscopy?
A colonoscopy is a medical procedure that involves inserting a thin, lighted tube with a camera to view the colon’s lining. A doctor performs a colonoscopy for different reasons:
- Screening exam. A screening colonoscopy is used to visualize the colon and remove potentially precancerous growths called polyps. A person who has a screening colonoscopy has no symptoms of bowel problems.
- Diagnosis. A diagnostic colonoscopy is done when a person has bowel symptoms, and a doctor needs to examine the colon for irregularities.
Doctors often perform these procedures using sedatives to help a person relax or under general anesthesia when asleep and unaware of the design.
Several factors influence the cost of a colonoscopy. Among them:
- Location. A colonoscopy can usually be done in an outpatient surgery center if a patient is healthy enough. It is usually less expensive than having it done in a hospital.
- Type of anesthesia. If a patient chooses general anesthesia over conscious sedation, costs increase due to the need for an anesthesia provider.
- Geographic area. Costs may vary depending on location in the country.
- Tissue samples. The tissue samples taken by the doctor are sent to a laboratory. This can increase the equipment costs to take the tissue samples and for a laboratory to evaluate them.
On average, a colonoscopy costs about $3,081. Patients with private health insurance will generally pay a deductible as part of their health plans. This could range from zero cost to $1,000 or more.
What is the cost with Medicare?
Colonoscopy costs with Medicare depend on whether the test is done for screening or diagnostic purposes.
Costs will also depend on whether your doctor accepts assignment with Medicare. This means they have signed an agreement with Medicare that says they will receive a Medicare-approved amount for the services.
According to Medicare.gov, Medicare will pay for screening colonoscopies once every 24 months if a doctor feels you’re at high risk of developing colon cancer.
A doctor may determine that a person is at high risk if they have a family history of colon cancer, colon polyps, or inflammatory bowel disease.
If you are not at high risk of developing colon cancer, Medicare will pay for a colonoscopy once every 120 months or ten years. If you’ve previously had a flexible sigmoidoscopy, which doesn’t involve looking at the entire colon, Medicare may cover a colonoscopy once every 48 months or four years.
Medicare may require you to pay a portion of the bill if the doctor finds a polyp or takes other tissue samples during a colonoscopy. At that time, Medicare may request payment of:
- 20% of the Medicare-approved amount for doctor’s time
- a copay if done in a hospital setting
For this reason, it is essential to know what you should pay if a polyp or biopsy (tissue sample) is removed during the procedure.
Also, the costs are different if the colonoscopy is for diagnostic purposes. For example, if you have digestive problems or signs of bleeding, a doctor may recommend a colonoscopy to diagnose the underlying cause.
What parts of Medicare cover colonoscopy?
Medicare includes different parts that provide coverage for different types of medical services. This section describes how each piece may or may not cover a colonoscopy.
Medicare Part A
Medicare Part A is the part of Medicare that covers hospital-related costs. If you need inpatient hospital care, Medicare Part A is the part of your insurance that pays these costs.
Sometimes someone may be hospitalized and need a colonoscopy. Let’s say you experience a gastrointestinal (GI) bleed. Medicare Part A will pay for these services, and Medicare Part B (more on this later) will pay for your doctor’s services while you’re in the hospital.
Medicare may require you to pay a copay or deductible for services you receive in the hospital. Generally, this is a one-time payment for up to 60 days of a hospital stay.
Medicare Part B
Medicare Part B is the part of Medicare that pays for medical services and preventive care. This is the part that covers outpatient care for services like a colonoscopy.
A person pays a monthly fee for Medicare Part B and has an annual deductible. The deductible varies from year to year, but in 2020 it is $198.
However, Medicare does not require you to meet your deductible before paying for a colonoscopy, and they will pay regardless of whether the colonoscopy is for screening or diagnostic purposes.
Medicare Part C
Medicare Part C, or Medicare Advantage, is a Medicare plan that includes Part A, Part B, and some prescription drug coverage. The Medicare Advantage plan must cover screening colonoscopies as mandated by the Affordable Care Act.
If you have Medicare Part C, the primary consideration is to make sure your anesthesia doctor and providers are in your plan’s network since many Medicare Advantage plans require you to seek care from specific providers.
Medicare Part D
Medicare Part D is prescription drug coverage that a person could buy and the other parts of Medicare. Some Medicare Part D plans may cover prescriptions for a bowel prep that helps clean out the colon before a colonoscopy.
Your Medicare Part D plan must explain which drugs are covered and which are not.
Medicare Supplement Plans (Medigap)
Medicare supplement insurance helps cover out-of-pocket costs associated with medical care. This includes expenses like copays and deductibles.
Your deductible does not apply to a colonoscopy; Medicare Part B will pay for a screening colonoscopy regardless of whether you’ve met your deductible.
However, if you incur additional costs because a doctor removes polyps or tissue samples, some Medicare supplement insurance plans may help pay these costs.
It’s essential to contact your insurance company before your colonoscopy to determine how much they might cover if you need polyps removed.
How can you know what your costs will be before a colonoscopy?
Ask your doctor’s office for a cost estimate before you have a colonoscopy. The billing department can usually estimate an average cost based on Medicare and other private insurance you may have.
If, for any reason, your doctor’s office believes that Medicare will not cover the costs of your colonoscopy, they must give you a notice called an “Advance Beneficiary Notice of Non-Coverage” (ABN).
Another consideration is whether you will receive anesthesia for the procedure: anesthesia providers and the doctor performing the colonoscopy bill separately.
If you have insurance that requires an in-network doctor, you may also need to ask who provides the anesthesia to ensure your costs are covered.
What other factors can affect how much you pay?
The main factor influencing how much you pay when you have Medicare is whether your doctor removes a polyp or takes other tissue samples for laboratory review. Of course, you can’t predict whether or not you have a polyp, which is why the doctor is doing the exam.
For this reason, it’s best to ask your doctor’s office for an estimate of charges if you have a polyp removed.
If your doctor’s office can’t provide this estimate or if you have additional questions, you can also contact the US Centers for Medicare & Medicaid Services. You can do this by calling 1-800-MEDICARE (1-800-633-4227) or going to Medicare.gov.
A colonoscopy is an important screening test that can detect signs of colorectal cancer.
Medicare covers the cost of the procedure for screening purposes, but there are considerations if your doctor has to remove polyps, as well as fees for anesthesia. Talk to your doctor’s office to get an estimate of these costs so you can anticipate them when scheduling your test.