If you have a family history of colon cancer, you might be concerned with getting preventive care to catch any early signs. This article will explain how Medicare covers preventive care services, like colonoscopies, to detect colon cancer.
Key Takeaways
- A colonoscopy is a medical procedure used to diagnose any abnormalities within your intestinal tract by using a camera-tipped tube.
- Medicare fully covers colonoscopies every 24 months for high-risk beneficiaries and every 10 years for other beneficiaries.
- Other services needed during a colonoscopy will still require paying into a deductible or a coinsurance.
- Any premedication required before a colonoscopy is covered by a Medicare Part D plan.
- Medicare Advantage plans will cover colonoscopy services, but they may be restricted to in-network providers.
- Medigap will help cover the out-of-pocket costs for any additional services you need when receiving a colonoscopy.
- Medigap will not help with a colonoscopy because it is fully covered by Medicare, it does not need to help.
What Is A Colonoscopy?
A colonoscopy is a diagnostic exam used to search for any abnormalities in your gastrointestinal tract. This is done by inserting a small camera at the end of a flexible cable tube into your rectum, allowing the doctor to see the walls of your colon through an attached monitor. Patients are provided with sedation medication before the procedure to reduce discomfort.1Mayoclinic.org, “Colonoscopy“, Accessed December 3, 2021
The colonoscopy tube can also be used to perform surgery by feeding special surgical tools through the length of the tube. This allows the doctor to remove any potentially cancerous polyps or retrieve tissue samples from the lining of your intestine without the need for major surgery.1Mayoclinic.org, “Colonoscopy“, Accessed December 3, 2021
A colonoscopy is often used as a preventive care service to screen for early signs of colon cancer. It can also be used to investigate symptoms of intestinal distress, such as:1Mayoclinic.org, “Colonoscopy“, Accessed December 3, 2021
- Abdominal pain
- Rectal bleeding
- Chronic constipation
- Chronic diarrhea
When Does Medicare Cover Colonoscopies?
Medicare covers the full cost of a screening colonoscopy once every 24 months if you’re at high risk for colorectal cancer. According to the Centers for Medicare & Medicaid Services, “high risk” means someone meets one or more of these criteria:2Medicare.gov, “Your Medicare Benefits“, Accessed December 3, 2021
- Has a personal history of colorectal cancer; adenomatous polyps, a form of polyp that is benign but can become cancerous; or an inflammatory bowel disease such as Crohn’s disease and ulcerative colitis.
- Has a close relative — a parent, sibling, or child — who has had colorectal cancer or an adenomatous polyp.
- Has a family history of inherited syndromes linked to colorectal cancer, such as familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer, also known as Lynch syndrome.
If you are at an average risk factor for these conditions, Medicare provides coverage for the test every ten years. If you had a previous flexible sigmoidoscopy, then Medicare covers it every four years.3Medicare.gov, “Colonoscopies“, Accessed December 3, 2021
Medicare fully covers the cost of a colonoscopy from a Medicare-approved that accepts Medicare assignment. With that said, for any polyps or abnormal tissues that are found and removed during the colonoscopy, you will have to pay the Medicare-approved amount for those removals.3Medicare.gov, “Colonoscopies“, Accessed December 3, 2021
The annual Medicare Part B deductible does not apply. Medicare will pay its share whether or not you have met your deductible for the year.3Medicare.gov, “Colonoscopies“, Accessed December 3, 2021
Premedication
If you are going to receive a colonoscopy, you will be prescribed a bowel preparation medication, such as Suprep Bowel Prep (sodium/potassium/magnesium), to clear your bowel the day before the procedure. Most Medicare Part D plans cover at least one bowel preparation medication.4Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 3, 20211Mayoclinic.org, “Colonoscopy“, Accessed December 3, 2021
Do Medicare Advantage Plans Cover Colonoscopies?
Medicare Advantage plans will cover preventive care services such as colonoscopies, as they are required to provide the same coverage as Medicare Part A and Part B (Original Medicare). The sticking point, however, is that Medicare Advantage members must use in-network services, facilities, and providers.5Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 3, 2021
Since a colonoscopy is a Medicare-approved service, Medicare Advantage plans are required to cover them. However, if you require services such as polyp removal, your out-of-pocket costs with a Medicare Advantage plan will vary. Check with your plan for details.
Summary
Medicare will cover the full cost of a colonoscopy, as it is a critical preventive service for catching early symptoms of colon cancer. However, if you require any additional procedures to remove abnormalities in your colon, you will be responsible for the remaining 20 percent after Medicare pays its share. Consult with your doctor about what the procedure may cost you if they find anything abnormal so that you can properly prepare for the results.
Citations
- 1Mayoclinic.org, “Colonoscopy“, Accessed December 3, 2021
- 2Medicare.gov, “Your Medicare Benefits“, Accessed December 3, 2021
- 3Medicare.gov, “Colonoscopies“, Accessed December 3, 2021
- 4Medicare.gov, “What Medicare Part D drug plans cover“, Accessed December 3, 2021
- 5Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 3, 2021