Let’s learn more about Medicare’s role in paying for colonoscopies and other colorectal screenings.
What Is a Colonoscopy?
A colonoscopy is a common way to screen for colorectal cancers. It’s a medical procedure used to identify abnormalities or changes in a patient’s large intestine or rectum. Colonoscopies involve the use of a colonoscope, a flexible tube with a very small video camera that can navigate the rectum and colon. The colonoscope can also take tissue samples or remove abnormal tissue, such as a polyp. A doctor might recommend a colonoscopy if you experience intestinal-related problems such as abdominal pain, chronic diarrhea, or rectal bleeding. Physicians often recommend colonoscopies for patients 50 and older to screen for colon cancer. Colorectal cancers are the third most common type of cancer in the U.S., excluding skin cancer, according to the American Cancer Society (ACS). The ACS estimates that in 2021 there will be more than 104,000 new colon cancer diagnoses and over 45,000 new rectal cancer diagnoses. In their arsenal of colorectal cancer prevention, physicians also employ other types of screening methods, such as barium enemas and multi-target stool DNA tests. If you’re 45 years old or older, your doctor may recommend that you begin periodic colorectal cancer screening.
Who Needs a Regular Colonoscopy?
Colorectal cancers pose an average risk for folks who’ve never had a colorectal cancer, hereditary colorectal cancer syndrome, inflammatory bowel disease, radiation treatment to the abdomen or pelvis, and those who don’t have a history of colorectal cancers in their families, according to the ACS. People who have had one or more of those conditions have a higher risk of colorectal cancers. For individuals with an average risk of colorectal cancers, the ACS recommends regular screenings, starting at age 45, including:
Colonoscopies every 10 yearsCT colonoscopies (a minimally invasive procedure that doesn’t require insertion of a colonoscope) every five yearsFlexible sigmoidoscopies (an invasive procedure similar to a colonoscopy, using a sigmoidoscope) every five years
People in good health should undergo colorectal cancer screenings up to age 75, the ACS recommends. For individuals aged 76 to 85, decisions on colorectal screening should be based on their prior screening history, life expectancy, and overall health. The ACS doesn’t recommend colorectal cancer screening for people over age 85. Colonoscopies don’t pose many risks. But on rare occasions, a colonoscopy may cause bleeding from a tissue sample or polyp removal site, perforation of the rectum or colon, or a reaction to a sedative given during the procedure.
Medicare Coverage for Colonoscopies
Medicare Part B covers most or all colonoscopy costs. But Medicare sets limits on how often it will pay for a colonoscopy or other type of colorectal cancer screening. Medicare bases some limits on an individual’s risk level for colorectal cancers.
Who qualifies for Medicare?
People aged 65 and older, disabled individuals, and people with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS) can qualify for Medicare. Medicare Part A pays hospital costs and Medicare Part B covers medical costs such as doctor visits and outpatient treatments and procedures like colonoscopies.
How often can I get a colorectal cancer screening?
Medicare sets limits on how often it will pay for colorectal cancer screenings, based on the type of procedure.
Barium enema: Every four years for people at average risk of colorectal cancers; every two years for individuals at high risk.Colonoscopy: Every five years for people at average risk; every two years for high-risk individuals; and four years after a flexible sigmoidoscopy screening.Fecal occult blood test: For people aged 50 and older, every 12 months.Flexible sigmoidoscopy: 10 years following a colonoscopy, every four years following a barium enema, or flexible sigmoidoscopy.Multi-target stool DNA test: Once every three years if:You’re 50 to 85Don’t display symptoms of colorectal diseaseYou are at average risk for colorectal cancersYou don’t have a family history of adenomatous polyps, colorectal cancers, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer
How Much Does a Colonoscopy Cost with Medicare?
Medicare doesn’t limit colonoscopy coverage based on age, though it does limit how frequently you can get one. Medicare Part B covers colonoscopy costs if your physician accepts assignment, which means they accept the amount Medicare approves for the procedure and agree to receive payment directly from Medicare. On average, Medicare recipients pay $0 for colonoscopies, according to the U.S. Centers for Medicare and Medicaid Services. But if the doctor removes a polyp or takes a tissue sample during the screening, and the colonoscopy takes place in a hospital, you may have to pay a copayment and 20% of the Medicare-approved amount for the physician’s services.
Additional Medicare Coverage Options
Medicare-approved private insurance companies sell Medicare Advantage plans. Often called Medicare Part C, Medicare Advantage plans are a way to get your Part A and B benefits and are required to provide complete Part A and Part B coverage, including coverage for colonoscopies. However, they usually require you to get services within the plan’s network of providers. Medigap, also sold by private insurers, provides supplemental Medicare coverage. It helps pay out-of-pocket costs such as coinsurance, copayments, and deductibles. So, if your doctor removes a polyp or takes a tissue sample during a colonoscopy, some Medigap plans will pay your 20% coinsurance or copayment.
