Yes. The Affordable Care Act requires Medicare and private insurers to cover the costs of colorectal screenings, which include a colonoscopy. A colonoscopy is an important health screening that can help prevent and treat colon cancers through the removal of polyps or precancerous growths.
Medicare will cover a colonoscopy every 24 months in people who are at high risk for colorectal cancer and every 180 months for people who are not at high risk. There is no age requirement.
The U.S. Preventive Services Task Force recommends individuals have a colonoscopy beginning at age 50 and continuing until they’re at least 75. If you have a family history of colon cancer or other cancer risk factors, some doctors may recommend that you get one earlier.
According to the Department of Health and Human Services, Medicare spent an estimated $1.3 billion on colonoscopy reimbursement in 2015.
A colonoscopy is a medical procedure that involves inserting a thin, lighted tube with a camera on it to view the lining of the colon. A doctor performs a colonoscopy for different reasons:
- Screening. A screening colonoscopy is used to visualize the colon and potentially remove precancerous growths called polyps. A person having a screening colonoscopy isn’t having symptoms of intestinal problems.
- Diagnostic. A diagnostic colonoscopy is performed when a person is having intestinal symptoms, and a doctor needs to exam the colon for irregularities.
Doctors typically perform these procedure types using sedation medications to help a person relax or under general anesthesia, where a person is asleep and unaware of the procedure.
Several factors go into how much a colonoscopy costs. These include:
- Location. If a patient is healthy enough, they can usually have a colonoscopy at an outpatient surgery center. This is usually less expensive than a colonoscopy in a hospital setting.
- Anesthesia type. If a patient selects general anesthesia over conscious sedation, the costs increase due to the need for an anesthesia provider.
- Geographic area. Costs can vary by location in the country.
- Tissue sampling. If a doctor takes tissue samples, they’ll send them to a laboratory. This can increase costs for equipment to sample the tissue and for a laboratory to evaluate it.
On average, a colonoscopy costs about $3,081. Patients with private health insurance will usually pay a deductible as part of their individual health plans. This may range from no cost to $1,000 or more.
Colonoscopy costs with Medicare depend on whether the colonoscopy is being performed for screening or diagnostic purposes.
Costs will also depend on whether your doctor accepts assignment with Medicare. This means they have signed an agreement with Medicare that says they’ll accept a Medicare-approved amount for services.
According to Medicare.gov, Medicare will pay for screening colonoscopies once every 24 months if a doctor considers you to be at high risk for colon cancer.
A doctor may determine you’re at high risk if you have a family history of colon cancer or you have a history of colon polyps or inflammatory bowel disease.
If you’re not at high risk for colon cancer, Medicare will pay for a colonoscopy once every 120 months, or 10 years. If you’ve previously had a flexible sigmoidoscopy, which doesn’t involve viewing the entire colon, Medicare may cover a colonoscopy once every 48 months, or 4 years.
Medicare may ask you to pay a portion of the bill if your doctor finds a polyp or takes other tissue samples during a colonoscopy. At that time, Medicare may ask you to pay:
- 20 percent of the Medicare-approved amount for your doctor’s time
- a copayment if you’re in a hospital setting
For this reason, it’s important to know what you may pay if you have a polyp or biopsy (tissue sample) removed during the procedure.
Also, the costs are different if the colonoscopy is for diagnostic purposes. For example, if you’re having digestive problems or signs of bleeding, a doctor may recommend a colonoscopy to diagnose the underlying cause.
Medicare includes different parts that provide coverage for different types of medical services. This section describes how each part may or may not cover a colonoscopy.
Medicare Part A
Medicare Part A is the part of Medicare that covers hospital-related costs. If you require inpatient care in a hospital, Medicare Part A is the portion of insurance that pays for these costs.
Sometimes, you may find yourself in the hospital and require a colonoscopy. Say you experience a gastrointestinal (GI) bleed. Medicare Part A will pay for these services, and Medicare Part B (see below) will pay for your doctor’s services while you’re in the hospital.
Medicare may require you to pay a copay or deductible for services you receive in the hospital. This is usually one lump sum for up to 60 days of a hospital stay.
Medicare Part B
Medicare Part B is the portion of Medicare that pays for medical services and preventive care. This is the part that covers outpatient care like a colonoscopy.
However, Medicare doesn’t require you to meet your deductible before it’ll pay for a colonoscopy, and they’ll pay regardless if the colonoscopy is for screening or diagnostic purposes.
Medicare Part C
Medicare Part C, or Medicare Advantage, is a Medicare plan that includes Part A, Part B, and some prescription drug coverage. A person’s Medicare Advantage plan must cover screening colonoscopies as the Affordable Care Act mandates.
The major consideration if you have Medicare Part C is to ensure the doctor and anesthesia providers are in-network for your plan, since many Medicare Advantage plans require you to seek care with specified providers.
Medicare Part D
Medicare Part D is prescription drug coverage a person may purchase in addition to their other Medicare parts. Some Medicare Part D plans may cover prescriptions for a bowel preparation to help clean out the colon prior to a colonoscopy.
Your Medicare Part D plan should come with an explanation of what medications are covered and which ones are not.
Medicare supplement plans (Medigap)
Medicare supplement insurance helps cover out-of-pocket costs associated with healthcare. This includes costs like copayments and deductibles.
Your deductible doesn’t apply to a colonoscopy — Medicare Part B will pay for a screening colonoscopy regardless of whether you’ve met your deductible.
However, if you do incur additional costs because a doctor removes polyps or tissue samples, some Medicare supplement insurance plans may help pay for these costs.
You’ll need to contact your insurance company prior to the colonoscopy to find out how much they may cover if you require polyp removal.
Ask your doctor’s office for an estimate of costs before you have a colonoscopy. The billing department can usually estimate an average cost based on Medicare and other private insurance you may have.
If for any reason your doctor’s office thinks Medicare won’t cover your colonoscopy costs, they’re required to give you a special notice called an Advance Beneficiary Notice of Noncoverage.
Another consideration is if you’ll receive anesthesia for the procedure. Anesthesia providers bill costs separately from the doctor performing the colonoscopy.
If you have insurance that requires an in-network doctor, you may also need to ask who’s providing the anesthesia to ensure that your costs are covered.
What other factors may affect how much you pay?
The main factor that affects how much you pay when you have Medicare is if your doctor removes a polyp or takes other tissue samples for laboratory review. Of course, you can’t predict if you have a polyp or not — that’s why the doctor is doing the screening in the first place.
For this reason, it’s best to ask your doctor’s office for an estimate of charges if you do have a polyp removed.
If your doctor’s office is unable to provide this estimate or you have further questions, you can also contact the U.S. Centers for Medicare & Medicaid Services. You can do this by calling 1-800-MEDICARE (1-800-633-4227) or visiting Medicare.gov.
A colonoscopy is an important screening test that can detect signs of colorectal cancer.
Medicare covers the cost of the procedure for screening purposes, but there are considerations if your doctor has to remove polyps and anesthesia fees. Talk to your doctor’s office to obtain an estimate of these costs so that you can anticipate them when scheduling.
Created for Greatist by the experts at Healthline. Read more