Every year in the U.S. there are thousands of adults that have prevented the development or chance of colon cancer spreading by having a routine colonoscopy. It is even more crucial to continue to feel healthy and get routine checkups as you get older. Those that are of high risk for colon cancer and enrolled in Medicare have may have coverage for a colonoscopy once every two years. For those that are of lower risk may have coverage every four-ten years depending on the risk level. The percentage that Medicare covers may also vary depending on the specific circumstances. Understanding more about the procedure and coverage for a colonoscopy allows you to plan for healthcare costs.
Why Would I Need a Colonoscopy?
A colonoscopy involves the doctor inserting a flexible scope into the rectum and threading it through the colon. The scope has a camera attached and allows the doctor to view the intestines. The procedure is done for a few reasons:
- A colonoscopy can identify polyps, tumors, and other abnormalities within the colon.
- According to the American Cancer Society, in the United States, colon cancer is the third most commonly diagnosed cancer. It is estimated that over 106,000 news cases of colon cancer will be diagnosed in 2022. Getting this procedure done can help the spread of cancer at an early stage.
- Your doctor may also recommend a colonoscopy in other cases, such as if you have an inflammatory bowel disease, to monitor the condition.
Fortunately, the death rate from colon cancer has been dropping for the last few decades. One reason for the declining death rate is likely colon cancer screening. According to the National Cancer Institute, colonoscopy significantly decreases the risk of dying from colorectal cancer.
How Often Will Medicare Cover the Cost of a Colonoscopy?
For preventive screening, Medicare covers a colonoscopy at specific intervals, including:
- Once every 2 years: Medicare covers a colonoscopy at this interval for people that are at high risk of developing colon cancer. Someone may be deemed at high risk if they have a family history of colon cancer, have inflammatory bowel diseases, or advanced polyps.
- Once every 4 years: Some people opt to get a sigmoidoscopy instead of a colonoscopy. A sigmoidoscopy is not inserted into the colon as far as a colonoscopy. It is only inserted up to the sigmoid colon. Medicare covers a colonoscopy 48 months after a person has had a previous sigmoidoscopy.
- Once every 10 years: Medicare covers a colonoscopy once every ten years for people that are not considered at high risk for developing colon cancer.
How Much Does a Colonoscopy Cost with Medicare?
Medicare may pay for a colonoscopy as long as the doctor performing the test participates in Medicare reimbursement. According to the Centers for Medicare & Medicaid Services, the amount Medicare pays for a colonoscopy may vary depending on how the doctor classifies the test. Medicare covers the cost of a colonoscopy differently depending on whether the test was done as a preventive screening or done as a diagnostic test:
- A diagnostic colonoscopy is used to identify problems due to symptoms. For example, if someone has blood in their stool, it would require diagnostic tests, such as a colonoscopy. Medicare will cover 80% of the cost.
- A preventive colonoscopy is one performed to screen for colon cancer. Medicare will cover 100% of the cost.
However, a Medicare colonoscopy loophole may change how Medicare covers the procedure. A routine preventive colonoscopy could turn into a diagnostic colonoscopy if a polyp was found and removed. This change meant an individual may have to unexpectedly cover 20% of the cost. However, advocacy groups worked to change the Medicare colonoscopy loophole and were successful. A bill was passed in 2020 called the Removing Barriers to Colorectal Cancer Screening Act. The bill gradually phases out-of-pocket costs for a preventive colonoscopy that turns into a diagnostic one.
If you have a Medicare Part D plan, which covers drugs, that will likely cover the prep kit needed before a colonoscopy for the colon cleanse. Most Medicare Advantage plans also cover the prep kit. If you do not have a drug plan or a Medicare Advantage plan, you may have to pay out of pocket for the prep kit.
Does Medicare Cover Other Colorectal Cancer Screenings?
Medicare does cover other types of colorectal cancer screenings. Different rules may apply to each test. Consider the following:
- Fecal occult blood tests: This screening test detects blood in the stool. Medicare covers the cost for people aged 50 and older every 12 months.
- Multi-target stool DNA test: This test detects blood in the stool but also DNA mutations that may indicate cancer. Medicare covers every three years in the following instances:
- You are between the ages of 50 and 85
- Do not have symptoms of colorectal cancer
- You are at average risk of developing colon cancer (no personal or family history)
- Sigmoidoscopy: This test allows the doctor to view the sigmoid colon to check for abnormalities. Medicare covers the cost every four years after a previous sigmoidoscopy and every 10 years following a colonoscopy.
- Double-contract barium enema: A barium enema creates an x-ray of the colon to help identify abnormal areas. Medicare covers it for people aged 50 and above every 48 months instead of a colonoscopy or for people at high risk, once every 24 months.
It is important to keep in mind that the best type of colon cancer screening often depends on your individual risk factors. Discussing these options with your medical provider is the best plan.
- Colorectal Cancer Screenings, CMS.
- Colorectal Cancer Screening Acts of 2020, Gov track.
- Methods Used to Screen for Colorectal Cancer, National Cancer Institute.