Medicare covers the costs of screening colonoscopies at specific time intervals, based on a person’s risk for colon cancer. For those with Medicare, the test is usually free. However, a person may have to pay out-of-pocket costs if they need polyp removal or use anesthesia services for their colonoscopy.
According to the Centers for Disease Control and Prevention (CDC),
The CDC also note that health authorities in the U.S. are currently aiming to perform screening for 80% of people between 50 and 75 years of age by the year 2024.
This target may not be achievable, however, as many people cannot afford a colonoscopy. To remedy this, Medicare may make colon cancer screening more accessible for those with an increased colon cancer risk, such as those aged 50–75 years.
In this article, we explain how Medicare covers colonoscopy costs and what a person can expect to pay out-of-pocket for the procedure.
Medicare covers screening colonoscopy costs as long as the doctor “accepts assignment.”
Accepting assignment means the doctor who will perform the colonoscopy agrees to Medicare reimbursing them at a standard rate for screening colonoscopies.
Medicarewill cover screening colonoscopies at the following intervals:
- Once every 24 months: This interval is for people who have a high risk of colorectal cancer due to a family or personal history of the disease.
- Once every 120 months, or 10 years: Medicare will fund this after a previous colonoscopy screening or every 48 months after a person has had a flexible sigmoidoscopy. This is an examination in which the doctor inserts the colonoscope into the sigmoid colon but no deeper.
If a doctor accepts assignment and does not view or remove polyps during a colonoscopy, a person with Medicare does not pay anything for the test. Polyps are growths in the lining of the rectum and colon.
While many polyps are not cancerous in the beginning, they may develop into colon cancer over time.
It is challenging for a doctor to predict the presence of polyps before a colonoscopy, and they are usually so tiny that a person will not be aware of them. For this reason, colon cancer screenings are vital for identifying polyps.
An estimated one-third of people receiving a colonoscopy do so under anesthesia, according to the Kaiser Permanente Washington Health Research Institute. This means the doctor gives them numbing medications that make the procedure easier to tolerate.
In 2015, the Centers for Medicare & Medicaid Services (CMS) announced they would not charge people a copayment or apply a deductible for Medicare enrollees who received anesthesia during a routine colonoscopy. The CMS expanded this coverage in the hopes of incentivizing more people to get a colonoscopy.
A screening colonoscopy becomes a diagnostic colonoscopy when a doctor has to remove polyps during the procedure.
If this occurs, a person with Medicare will need to cover the following costs out-of-pocket:
- 20% of the Medicare-approved amount of the doctor’s services
- a copayment if the doctor performs the procedure in a hospital setting
Medicare funds colonoscopy under its Part B plans. People with Medicare Part B have to meet a deductible, then pay 20% of the Medicare-approved cost of a service or treatment.
If a doctor identifies a polyp or several polyps, they will likely recommend that a person returns sooner than 10 years for a colonoscopy. At this time, the colonoscopy will be diagnostic and not routine.
As a result, a Medicare enrollee may be responsible for costs that include:
- anesthesia services
- physician services
- hospital facilities
- laboratory testing of the polyp for cancer
While receiving a diagnostic colonoscopy can have a financial impact, it is important to remember the cost of colorectal cancer is much higher than the preventive screening.
The ability to identify and remove precancerous growths before they grow and become malignant is vital to colorectal cancer prevention.
A colonoscopy is an outpatient procedure. During a colonoscopy, a doctor examines the large intestines by inserting a thin, flexible scope into the rectum. The scope has a light at the end of it.
By advancing this scope through the colon, a doctor can create images of the colon’s lining and identify any unusual growths. This can include polyps.
A colonoscopy can help a doctor screen for colon cancer and remove polyps to help prevent colon cancer.
According to the U.S. Preventive Services Task Force (USPSTF), colon cancer is the second-leading cause of cancer death in the U.S. These screenings can enable life-saving treatment in the early developmental stages of cancer.
The USPSTF currently recommend that adults begin colorectal cancer screenings at 50 years of age and continue regular screenings until they reach 75 years. A person with a significant family history of colon cancer may benefit from screenings that start at an earlier age.
Not all colonoscopies are for screening. A colonoscopy can also be a diagnostic procedure to identify the cause of active symptoms. Doctors may use colonoscopies to diagnose or monitor the following conditions:
- underlying symptoms, such as diarrhea, bloating, or other changes in stool habits
- irritable bowel disease (IBD), a series of gastrointestinal conditions that include ulcerative colitis and Crohn’s disease
- bleeding from the rectum or blood in the stool
This difference between a screening colonoscopy and one that a person needs for diagnostic purposes can make a difference to Medicare reimbursement.
If a doctor recommends a colonoscopy, understanding the reason behind the referral can provide some clarity when it comes to coverage and out-of-pocket costs.
As long as a doctor accepts assignment, Medicare does not charge a person for screening colonoscopies.
If a doctor has to remove polyps, a person may be responsible for some costs, as the procedure would then become a diagnostic colonoscopy.
A doctor is responsible for providing individuals with an explanation called an Advance Beneficiary Notice of Non-coverage if they have reason to think that Medicare will not cover colonoscopy costs.