Does Medicare Cover Colonoscopy?

Does Medicare Cover Colonoscopy?
Medicare

According to the National Cancer Institute, colon cancer is the third most common cancer type among men and women in the United States. However, approximately 30% of adults aged between 50 and 75 have never been screened for colon cancer.

Given that colonoscopy is quite effective in detecting colon cancer in its early stages, it is surprising how more than 20 million seniors haven’t received this or any other type of colon cancer screening.

Since old age is one of the risk factors of colon cancer, many individuals out there have been left wondering whether Medicare covers colonoscopy. The simple answer is yes.

So, if you are a Medicare beneficiary and wondering to what extent your Medicare will cover colonoscopy, you are in the right place. Read this post to learn more about Medicare coverage and colonoscopy.

What Is Colonoscopy?

In simple terms, a colonoscopy is a medical procedure that involves examining the large intestines by carefully inserting a thin and flexible scope into the rectum. The scope usually has a light at its end, which allows the doctor to capture clear images of the colon’s lining and identify any unusual growths.

Some of the unusual growths that the doctor may be looking for are polyps. Typically, a colonoscopy can help your doctor screen for colon cancer and get rid of polyps to prevent the development of colon cancer.

Since colon cancer is the second leading cause of cancer death in the United States, regular screening can help with life-saving treatment if the disease is detected early.

The U.S Preventive Services Task Force recommends that adults start colon cancer screening at 50 years and adhere to regular screenings until they hit 75 years.  If you have a family history of colon cancer, you may benefit greatly from regular screenings starting at an earlier age.

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However, not all colonoscopies are for colon cancer screening.  A colonoscopy can also be used as a diagnostic procedure to identify potential causes of active symptoms. Your doctor may use a colonoscopy to diagnose or monitor the following medical conditions;

  • Irritable bowel disease (IBD), a series of gastrointestinal conditions that may include ulcerative colitis and Crohn’s disease.
  • Bleeding from the rectum or presence of blood in the stool.
  • A wide range of underlying symptoms such as bloating, diarrhea, and other changes in your stool habits.

If your doctor recommends a colonoscopy, ensure you understand the reason behind the recommendation to provide clarity when it comes to Medicare coverage and out-of-pocket costs.

Does Medicare Cover Colonoscopy?

The simple answer is yes. Thanks to the Affordable Care Act, Medicare and other private health insurance companies are required to cover the cost of colorectal screenings, which include colonoscopies.

A colonoscopy is an essential health screening that can help prevent and even treat colon cancer by removing precancerous and polyp growths.

Typically, Medicare will cover the cost of colonoscopy once every two years for individuals at a high risk of developing colon cancer and once every 180 months for those who aren’t at high risk. There is no age requirement for coverage.

According to the Department of Health and Human Services, Medicare spends approximately $1.3 billion on colonoscopy reimbursement every year.

Does Medicare Cover Diagnostic Colonoscopy Costs?

As mentioned earlier, a screening colonoscopy becomes a diagnostic colonoscopy when your doctor has to remove polyps during the procedure. If this happens, you may be forced to foot part of the medical bill.

Typically, you will be required to pay the following costs out-of-pocket:

  • A copayment if your doctor performs the procedure in a hospital setting.
  • 20% of the Medicare-approved amount of the doctor’s services.

Medicare usually funds colonoscopy under Part B plans. All individuals with Medicare Part B must meet a deductible and pay 20% of the Medicare-approved cost of treatment or service.

If your doctor identifies signs of polyp growth during the procedure, he/she may recommend you return to the hospital sooner than ten years for another colonoscopy. At this time, the procedure will be diagnostic and not routine screening.

As a result, you may be forced to foot some costs that include;

  • Physician services.
  • Laboratory testing of the polyp for possible colon cancer.
  • Hospital services.
  • Anesthesia services.

Although the overall cost of having a diagnostic colonoscopy may seem a little bit high, it is important to keep in mind that the cost of treating colon cancer is much higher than that of preventive screening.

How Can You Know If Your Medicare Covers Colonoscopy?

To find out if your Medicare plan covers colonoscopy, you need to talk to your primary doctor to find out why he/she is recommending the procedure. Is it for routine screening or diagnostic purposes? Are you considered a high-risk or low-risk patient for colon cancer?

If you have had a colonoscopy before, make sure you examine your medical records to find out when it was. Was it less than two years ago (for high-risk individuals) or less than ten years (for low-risk individuals)?

If you have been screened recently and don’t want to incur out-of-pocket charges, you may want to wait until your next colonoscopy is covered.

 

You should also ask your doctor whether he/she will charge a Medicare-approved amount and whether the procedure will be carried out at the doctor’s office or hospital setting.

Lastly, you need to call your insurance provider to confirm whether they will cover your colonoscopy cost. If you have Original Medicare Part B, you should be automatically covered for preventive screening up to the Medicare-approved amount.

If you have a Medigap or Medicare Advantage policy, you may have more comprehensive coverage. Be sure to call your insurance provider directly and find out what is covered under your plan.

The Bottom Line

As long as your primary doctor accepts Medicare assignment, you don’t have to pay anything for screening colonoscopies.

However, if the doctor has to remove some polyps, you may be responsible for some costs as the procedure stops being a screening colonoscopy and becomes a diagnostic colonoscopy.

Your doctor is fully responsible for providing you with a comprehensive explanation if he/she feels that Medicare can’t cover your colonoscopy costs.

Are you having challenges with your Medicare plan and want expert advice from licensed Medicare agents? Contact us today and let us help you.