Does Medicare cover a colonoscopy?
Colonoscopies are a common preventive exam to check for abnormalities, cancer, and diseases in the colon. Doctors typically look for polyps, a cluster of cells on the colon. Older adults are more susceptible to gastrointestinal diseases and colorectal cancer—in 2018, 67% of Americans aged 50–75 needed a colonoscopy based on the U.S. Preventive Services Task Force recommendations. Early detection is key to treating and managing any health condition, including colon cancer.
Fortunately, Medicare pays for many preventive care screenings, including colonoscopy exams. In this guide, we’ll share how often you can cover a colonoscopy with Medicare and answers to other frequently asked questions about the test.
Key takeaways:
Medicare fully covers a colonoscopy screening if you don’t need to remove any polyps or abnormal tissue.
If you have a colonoscopy where you need polyp or tissue removal, you’ll pay 15% of the Medicare-approved amount.
How often Medicare pays for a colonoscopy depends on your level of risk for cancer and other gastrointestinal diseases.
If you’re at high risk for colorectal cancer, Medicare covers a colonoscopy once every 24 months. If you’re at low risk for colorectal cancer, Medicare covers a colonoscopy once every 120 months.
What is a colonoscopy?
A colonoscopy is a diagnostic exam during which a medical professional checks the large intestine (colon) and rectum. Doctors who perform colonoscopies, gastroenterologists, specialize in the digestive system.
During the procedure, a gastroenterologist inserts a flexible and slender tube called a colonoscope through the rectum. The colonoscope has a light and a camera at its tip, allowing doctors to see the inside of the colon on an external monitor and diagnose conditions based on any abnormalities they detect.
What a colonoscopy screens for
You can undergo a colonoscopy for a number of reasons, including the following.
Screening for colorectal cancer: Colonoscopies are commonly used for routine screening to detect and prevent colorectal cancer, a type of cancer that begins in the colon or the rectum. If the procedure shows that you have precancerous polyps, you can get them removed before they develop into cancer.
Gastrointestinal symptoms: If you’re experiencing abdominal pain, changes in bowel behavior, rectal bleeding, or sudden weight loss, your doctor may recommend a colonoscopy to investigate the cause of these symptoms.
Monitoring and surveillance: Doctors may recommend more regular colonoscopies for people with a history of colorectal polyps or a family history of colorectal cancer.
Evaluation of inflammatory bowel diseases (IBD): In addition to detecting colorectal cancer, you can also get a colonoscopy to identify or assess inflammatory bowel diseases like Crohn's disease and ulcerative colitis.
What to expect during a colonoscopy
You’ll typically have to follow instructions for bowel preparation before the procedure so that your doctor can clearly view the large intestine. This involves a specific diet (usually consisting of light broths and water) and medications to cleanse your colon. You usually also have to refrain from eating for a period of time.
During the colonoscopy, doctors will provide you with a sedative to make the process more comfortable. If your gastroenterologist finds any polyps or other abnormalities, they may remove the growth(s) during the procedure.
After the procedure, healthcare providers will give you instructions on diet, activity, and any potential side effects or complications to watch for. If you had any biopsies or polyps removed during your colonoscopy, you’ll receive information about the results and any necessary follow-up steps.
Does Medicare cover colonoscopy procedures?
Yes, Medicare covers colonoscopy procedures. Medicare Part B covers preventive care, and colonoscopies are considered a preventive screening.
How often does Medicare cover a colonoscopy?
How often Medicare covers a colonoscopy depends on whether or not you’re at high risk for colorectal cancer.
If you’re at high risk for colorectal cancer, Medicare covers a colonoscopy once every 24 months.
If you’re at low risk for colorectal cancer, Medicare covers a colonoscopy once every 120 months.
Medicare also pays for a colonoscopy under two other situations:
48 months after a previous flexible sigmoidoscopy, another type of screening for colon and rectal cancer.
If you receive a positive result from a stool sample test, Medicare will cover a follow-up colonoscopy.
How Medicare covers a colonoscopy vs. diagnostic colonoscopy
With Medicare, you won’t have to pay anything for the colonoscopy screening itself if your healthcare provider accepts the Medicare assignment (most healthcare providers will accept assignment for a colonoscopy).
However, if you need a polyp or other tissue removed, you’ll have to pay for 15% of the service’s cost. It's called a diagnostic colonoscopy when you need a polyp removed during the procedure. For a diagnostic colonoscopy, you won’t have to worry about meeting your Part B deductible, and will only be responsible for paying 15% of the cost. If you have a Medicare Supplement plan, you can get some, or all, of your out-of-pocket costs covered.
Most of the time, once you reach your Part B deductible, Medicare pays for 80% of the cost of covered services, leaving you responsible for the remaining 20% out of pocket. The good thing about Medicare screenings is that you pay a lower percentage of the cost if a free, preventive exam turns into a diagnostic procedure. This applies even if you don’t reach your Part B deductible. This is why you only pay 15% of the cost of a diagnostic colonoscopy.
Does Medicare cover colonoscopy after Cologuard?
Medicare covers Cologuard, an at-home colon cancer screening test. But you may be wondering whether or not Medicare covers a colonoscopy after using a Cologuard kit. The answer is yes and no. Medicare would only cover a colonoscopy after Cologuard if you received a positive result. Otherwise, it will not pay for it. That being said, you can still get a colonoscopy covered once every 120 months if you’re at low risk for developing colon issues.
Does Medicare cover colonoscopy prep kits?
Colon preparation is vital to a successful colonoscopy. Your prescription drug plan (Part D) is responsible for covering the colonoscopy prep kits, which usually includes medication to clear your bowels. Most Part D plans cover colonoscopy prep kits, but you may have to pay a copay or coinsurance to receive it.
Protecting yourself with regular screenings
The best way to reduce your risk of developing colorectal cancer and gastrointestinal disease is with routine screenings. Medicare provides coverage for preventive screenings and helps pay for any diagnostic procedures as well.
Still have questions about Medicare coverage or how to maximize your Medicare benefits? Call us at 855-900-2427 for free, personalized support or schedule a time to talk now.