Does medicare cover colonoscopy?

Wondering what the cost of a colonoscopy is with Medicare? Learn what is covered and how to save.

If you’re at an age where you qualify for Medicare, that also means you’re at an age where routine colonoscopies are an essential part of your healthcare check-ups. Colorectal cancer is the third most common type in the United States, outside skin cancers. And with all kinds of cancer, early detection is key. If you’re due for your next colonoscopy and have Medicare, let’s find out if they cover the important screening.

Medicare coverage for colonoscopy

Does Medicare cover colonoscopy? Medicare’s first rule for colonoscopy coverage is that you’re over 45. After that, your coverage for a colonoscopy depends on your risk factors. Those at high risk of colorectal cancer, such as those with a family history of colorectal cancer or colon cancer, are allowed more frequent screenings. This policy also goes for individuals with inflammatory bowel diseases like Crohn’s disease or ulcerative colitis. 

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  • If you’re at high risk for colorectal cancer, Medicare pays for a colonoscopy every 24 months (two years). 
  • If you’ve had a previous flexible sigmoidoscopy or diagnostic test of the colon, then Medicare will pay for a colonoscopy every 48 months (four years). 
  • Medicare will pay for a colonoscopy every 120 months (10 years) if you’re not high-risk and at average risk. 

Following this timeline, Medicare pays for 100% of the routine screenings.

Medicare Part B covers the colonoscopy screenings and the drugs you’ll need for the anesthesia. However, if your healthcare provider orders a colonoscopy prep kit, this is typically paid for by Medicare Part D, which is prescription drug coverage under Medicare. 

While computed tomographic (CT) colonography, or virtual colonoscopies, have become popular since the 2000s, Centers for Medicare & Medicaid Services do not cover these procedures as they state there is inadequate evidence to determine if it’s an appropriate method of colorectal cancer screening.

Coverage for screening vs. diagnostic colonoscopies

A colonoscopy is a preventive screening, also called a preventive service, because it is a tool to prevent diseases and health problems. Medicare covers 100% of the cost of preventive care. That means you don’t have to pay any co-insurance or copays toward the Part B deductible if your doctor accepts Medicare assignment

“During routine colonoscopies, if polyps are found and removed, the procedure becomes a ‘therapeutic’ procedure, resulting in the beneficiary being responsible for a copay,” explained Michelle Robbins, a licensed insurance agent in Corona, California, with USInsuranceAgents.com.

This means that if during your screening colonoscopy, your doctor finds something and needs to perform a biopsy on growths or remove a polyp, Medicare no longer considers this colonoscopy screening a preventive service. Instead, Medicare now considers it a diagnostic colonoscopy. While Medicare Part B still pays for this service, they no longer pay 100% of it. Now, they’ll only cover 85% of the healthcare provider’s services, and you’ll need to pay a 15% copay of the Medicare-approved amount.

Medicare colonoscopy loophole

In the above situation where you go in for a routine colonoscopy screening, and a polyp is removed, turning it into a diagnostic colonoscopy, you’re now in the Medicare colonoscopy loophole because you’re on the hook for paying for a procedure you thought was entirely covered. However, in 2020 a bill was passed to stop these unexpected out-of-pocket costs that will be in full effect in 2030.

What is the cost of a colonoscopy with Medicare?

“Usually, there is no cost for colonoscopies,” said Robbins. “The procedure classification could change if a polyp or tissue is taken during the screening. If it’s within a hospital setting, a beneficiary may have to pay a copay of  15% of the physician’s services.”

A routine colonoscopy screening test will be free to a Medicare beneficiary unless an unforeseen polyp or growth is found during the procedure. Then you’ll need to pay for 15% of the procedure bill unless you have Medicare Supplement Insurance or a Medigap plan that helps cover copays and coinsurance not covered by Medicare.

You’ll also need a colonoscopy preparation kit to empty your bowels before having the procedure. Most Medicare Part D insurance plans will cover the cost of colonoscopy prep kits, but there may be a copay or coinsurance. 

The most commonly prescribed colonoscopy prep kit is the SUPREP Bowel Prep Kit (Na Sulfate-K Sulfate-Mg Sulf). According to SingleCare, the average cash price for this generic prep kit is $183 per 2, 177ML of 17.5-3.13-1.6GM/177ML solution.

No matter how old you get, Medicare will continue to pay for colonoscopies as long as you are over 45 and follow the allowed time frame. 

How to save on a colonoscopy with Medicare

Medicaid

If you’re low-income, you may qualify for your state’s Medicaid program. Medicaid will help cover the costs left over from a diagnostic colonoscopy if you need a polyp removed during your screening. You can see if you qualify for Medicaid here. 

Extra Help

Extra Help is another option for seniors living on a limited income. Extra Help gives financial help to those struggling with costs not covered by a Medicare Part D prescription drug plan, which could help pay for a bowel prep kit. You can see if you qualify here.

Medigap Plans

You can fill in the gaps that Original Medicare doesn’t cover with a Medigap plan (Medicare supplement insurance). These plans help cover the costs of copays, coinsurance, and deductibles.

Medicare Advantage Plans

Instead of using Original Medicare with Medicare Part A and Medicare Part B, you can use a Part C or Medicare Advantage Plan. These are offered by private health insurance companies and used in place of Original Medicare. Each state has different plans, but some may have better deals on prescription drugs and colonoscopy services that you can switch to during the enrollment period.

SingleCare

If you need help covering prescription drug costs, you should look at SingleCare, which offers coupons for discounts on thousands of medications. The generic Suprep Bowel Prep Kit runs at a cash price of $183 per 2, 177ML of 17.5-3.13-1.6GM/177ML Solution, but with SingleCare, you could pay as little as $14.



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