Does Medicare Pay For Colonoscopy Procedures?
Learn about Medicare’s coverage for colonoscopies and other screening tests for cancer.
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Medicare coverage can be difficult to understand if you’re new to the program. However, we’ve made it our mission to help seniors around the U.S. come to grips with everything to do with Medicare.
Colonoscopies are one of the best ways to ensure early diagnosis of colon or colorectal cancer and getting them regularly after the age of 45 is a must.
If you’re wondering if Medicare covers a colonoscopy, then read our guide to understand what they pay for, what they don’t, and when you can get Medicare to cover a colonoscopy.
Who Qualifies for Medicare?
Medicare is a health insurance program run by the Centers for Medicare and Medicaid Services (CMS) for people 65 and older, people under 65 with certain disabilities, and people of any age with end-stage renal disease (ESRD).
Medicare beneficiaries can enroll in Medicare Advantage Plans (like an HMO or PPO), Medicare Prescription Drug Plans, or both.
You can also get Medicare coverage by enrolling in a Medicare Cost Plan, a Medicare Medical Savings Account Plan, or a Demonstration/Pilot Program.
There are four parts to Medicare:
Medicare Part A is hospital insurance or inpatient coverage. With Medicare Part A, you’ll need to pay a deductible for your hospital stay and there is a monthly premium for people who haven’t contributed to Medicare through taxes for forty financial quarters.
Medicare Part B is outpatient medical insurance or nonhospital insurance. It covers preventive care such as a colonoscopy.
With Part B, you’ll pay 20% of the Medicare-approved amount after you've met your yearly deductible and Medicare will pay the remaining 80%.
Medicare Advantage (Previously Part C) are health plans that cover Part A and Part B costs and, in some cases, Part D.
They offer the same level of insurance as Original Medicare and often give members additional benefits, such as dental, vision, and hearing coverage.
Medicare Part D is prescription drug coverage that you can buy as part of your Medicare Advantage coverage or as a standalone prescription drug plan.
What Is Original Medicare?
Original Medicare is the federal Medicare program for hospital and general medical expenses.
Original Medicare is made up of Part A and Part B. This is different from Medicare Advantage, which are Medicare health plans that are run by private health insurance companies.
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Does Medicare Cover Colon and Colorectal Cancer Screenings?
Medicare beneficiaries can receive coverage for colon and colorectal screenings, as well as any necessary follow-up care.
Medicare will also cover a colonoscopy if it is considered medically necessary to diagnose or treat a condition.
If you have Original Medicare, you’ll be covered for one colonoscopy every 24 months if you’re at high risk for colon or colorectal cancer.
If you aren’t at risk of developing colon cancer, you’ll be covered for one colonoscopy screening test every ten years (120 months).
It will also cover the full cost of a colonoscopy 48 months after a previous flexible sigmoidoscopy, which is done to evaluate the lower part of the colon.
However, if your doctor removes a polyp during a colonoscopy, you may have to pay 20% of the cost for Medicare Part B expenses.
Medicare Advantage Plans may also offer coverage for screenings for a colonoscopy, as well as other preventive services.
Beneficiaries should check with their Medicare Advantage Plan to see what services are covered.
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Does Medicare Require Prior Authorization for a Colonoscopy?
Yes, you’ll need to get prior approval for the procedure from your physician if you want Medicare to cover your colonoscopy.
Generally, the process will involve:
1) Going to your doctor and getting a recommendation to see a specialist.
2) Visiting a specialist and having them submit a request for a colonoscopy.
3) Getting approval from Medicare to perform the procedure.
4) Having the colonoscopy procedure performed.
What Is a Colonoscopy?
A colonoscopy is a procedure used to examine the large intestine or colon. The procedure is performed using a long, flexible tube that is inserted through the rectum and into the colon.
A small camera attached to the tube allows the doctor to get a clear view of the inside of the colon. The procedure usually takes about 30 minutes, and most people do not experience any pain or discomfort.
Some people may feel a slight cramping sensation when the tube is first inserted, but this typically disappears within a few minutes.
The doctor may collect small tissue samples (biopsies) during the procedure for further testing. Colonoscopies are generally safe, and complications are rare.
The procedure is essential for detecting early signs of colon or colorectal cancer, which can be treated effectively if caught early.
What Is Colon or Colorectal Cancer?
Colon or colorectal cancer is a type of cancer that begins in the large intestine (colon) or the rectum (end of the colon).
According to the National Cancer Institute, colorectal cancer is the fourth most common cancer in men and women in the U.S.
Secondary cancers can also affect the colon and rectum, but then they are not colon or colorectal cancers.
Most cases of colon cancer begin as small, noncancerous (benign) clumps of cells called adenomatous polyps.
Over time, some of these polyps can become colon cancers. Doctors don't yet know exactly what causes colon cancer, but they have found several risk factors.
These include age, family history, smoking, obesity, lack of exercise, heavy alcohol use, treatment for ulcerative colitis or Crohn's disease, and eating a diet high in red or processed meats and low in fruits and vegetables.
African Americans are also at increased risk. Symptoms of colon cancer may include fatigue, abdominal pain or cramps, bloating, changes in bowel movements (such as diarrhea), bleeding from the rectum, or blood in the stool.
Source: Pexels
Screening Vs. Diagnostic Colonoscopies
Both screening and diagnostic colonoscopies can help detect any problems with the colon or rectum. There is a difference between the two procedures.
A screening colonoscopy is typically covered by Medicare and other insurance plans, as it is considered a preventative measure.
This type of colonoscopy is recommended for people over the age of 50 or those who have a family history of colorectal cancer.
On the other hand, a diagnostic colonoscopy is usually only covered by insurance if there are symptoms present that suggest a problem.
This procedure further investigates any potential issues found during a screening colonoscopy or diagnoses other issues related to bleeding or abdominal pain.
What Other Screenings Does Medicare Cover?
The cancer screenings that Medicare covers, include: mammograms, pap smears, colonoscopies, and prostate cancer screenings.
In addition to cancer screenings, Medicare also covers a range of other preventive services, such as screenings for diabetes and high cholesterol.
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Who Needs a Regular Colonoscopy?
Colonoscopies are an important preventative measure for colon cancer. Colonoscopies are typically performed once every ten years, but people with certain risk factors may need to be screened more frequently.
The American Cancer Society recommends that people at average risk for colon cancer begin regular colonoscopies at age 45. People at increased risk, such as those with a family history of the disease, may need to start earlier.
These risk factors include a personal history of colorectal cancer or polyps, a history of inflammatory bowel disease, and a family history of the disease.
If you have any of these risk factors, talk to your doctor about how often you should have a colonoscopy.
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How Much Does a Colonoscopy Cost with Medicare?
After you meet your deductible, you are still responsible for a portion of your medical bills. For example, if your coinsurance is 20%, you would be responsible for 20% of the cost of a colonoscopy, while Medicare would cover the other 80%.
The exact cost of a colonoscopy will vary depending on the facility where it is performed, but it typically ranges from $1,000 to $3,000.
It's essential to check with your specific plan to see what coinsurance amounts you are responsible for as you will be liable for this amount once you go for your treatment.
Example: Costs for a Colonoscopy with Medicare
Let’s say you need to go for a colonoscopy and you’re enrolled in Medicare Part A and B.
If you haven’t gone for a colonoscopy since you’ve joined and aren’t at risk for colon cancer, Medicare will pay the entire cost of the procedure.
However, if you’ve been for a colonoscopy in the last ten years while enrolled in Medicare, you’ll be partially covered and have to pay 20% of the cost of the procedure.
If your colonoscopy costs $1700, you’ll need to cover 20% of this ($340), and Medicare will pay the remaining balance.
However, you’ll also need to cover other out-of-pocket costs, such as your Part B deductible and monthly premium, before you are covered.
Deductible for 2022: $233 Monthly Premium: $170.10 Colonoscopy Coinsurance (20%): $340 Total Costs: $743.10
FAQs about Medicare and Colonoscopies
How many times does Medicare cover colonoscopy?
Original Medicare will cover the cost of a screening colonoscopy once every 120 months or ten years. If you are at a high-risk of developing colon cancer, Medicare will cover colonoscopies every 24 months.
How much does Medicare pay towards a colonoscopy?
Original Medicare will generally cover the entire cost of your colonoscopy if your medical provider accepts Medicare rates. However, you will have to pay 20% in coinsurance if a polyp or growth is detected and removed during the procedure.
Does Medicare require prior authorization for colonoscopy?
Yes, you will need to get prior authorization before you go for a colonoscopy if you want Medicare to cover the costs of the procedure.
Does Medicare pay for polyp removal?
Yes, Polyp removals performed during a colonoscopy will be covered under Part B and Medicare will cover 80% of the costs. You’ll need to pay 20% in coinsurance for the procedure.
How often should you have a colonoscopy after age 60?
If you are over the age of 60, you should go for a colonoscopy at least once every ten years. If you have a higher risk of developing colorectal cancer or polyps, you should go for a colonoscopy at least every 24 months.
Where Can I Learn More about Medicare Coverage?
Having regular colonoscopies as you age is vital to detecting colon cancer and ensuring your quality of life. Medicare will cover colonoscopies. However, you’ll need to go through the correct process to get approved.
If you’d like to learn more about Medicare coverage, visit our Medicare hub to find our latest articles. We have guides to help you understand enrollments, costs, and treatment, as well as information on how to get the best deal for your health care.
If you need assistance with your Medicare questions or want help finding a private health plan with excellent coverage, feel free to reach out to one of our Medicare agents today at 1-888-912-2132 or help@policyscout.com.