Insurance Coverage
Federal law
Coverage of colorectal cancer screening tests is required by the
Affordable Care Act (ACA), but the ACA doesn’t apply to health plans that were in place
before it was passed (called “grandfathered plans”). You can
find out your insurance plan’s grandfathered status by contacting
your health insurance company or your employer’s human resources
department. If your plan started on or after September 23, 2010, it must
cover colonoscopies and other colorectal cancer screening tests. If a
plan started before September 23, 2010, it may still have coverage requirements
from state laws, which vary, and other federal laws.
Private health insurance coverage for colorectal cancer screening
The Affordable Care Act requires health plans that started on or after
September 23, 2010 to cover colorectal cancer screening tests.
Although many private insurance plans cover the costs for colonoscopy as
a screening test, you still might be charged for some services. You may
have to pay part of the costs of anesthesia, the bowel prep kit, pathology
costs, and a facility fee. Review your health insurance plan for specific
details. Colonoscopies that are done to evaluate specific problems, such
as abdominal pain, intestinal bleeding, or anemia are usually classified as
diagnostic – and
not screening – procedures. If that’s the case, you may have to pay any
required deductible and co-pay. The same is true if colonoscopy is done
after a positive stool test (such as the gFOBT or FIT) or an abnormal
double-contrast barium enema or CT colonography. Some insurance plans
also consider a colonoscopy diagnostic if something is found (like a polyp)
during the procedure that needs to be removed or biopsied.
Before you get a screening colonoscopy, ask your insurance company if you
will be required to pay and if so, how much. Find out if this amount could
change based on what’s found during the test. This can help you
avoid surprise costs. If you do have large bills afterward, you may be
able to appeal the insurance company’s decision.
Medicare coverage for colorectal cancer screening
Medicare covers an initial preventive physical exam for all new Medicare beneficiaries.
It must be done within one year of enrolling in Medicare. The “Welcome
to Medicare” physical includes referrals for preventive services
already covered under Medicare, including
colon cancer screening tests.
If you’ve had Medicare Part B for longer than 12 months, a yearly
“wellness” visit is covered without any cost. This visit is
used to develop or update a personalized prevention plan to prevent disease
and disability. Your provider should discuss a screening schedule (like
a checklist) with you for preventive services you should have, including
colon cancer screening.
What colorectal cancer screening tests does Medicare cover?
Fecal occult blood test (FOBT) or
fecal immunochemical test (FIT) every year for all Medicare beneficiaries 50 years and older.
Stool DNA test (Cologuard) every 3 years for Medicare beneficiaries 50 to 85 years old
who do not have symptoms of colorectal cancer and who do not have an increased
risk of colorectal cancer.
Flexible sigmoidoscopy every 4 years for those 50 years and older, but not within 10 years of
a previous colonoscopy.
Colonoscopy
-
Every 2 years for those at high risk (regardless of age)
-
Every 10 years for those who are at average risk
-
4 years after a flexible sigmoidoscopy for those who are at average risk
Double-contrast barium enema if a doctor determines that its screening value is equal to or better
than flexible sigmoidoscopy or colonoscopy:
At this time, Medicare does not cover the cost of
virtual colonoscopy (CT colonography).
If you have questions about your costs, including deductibles or co-pays,
it’s best to speak with your insurance company.
What would a Medicare beneficiary expect to pay for a colorectal cancer
screening test?
-
FOBT/FIT: Covered at no cost* for those age 50 years or older (no co-insurance or
Part B deductible).
-
Stool DNA test (Cologuard): Covered at no cost* for those age 50 to 85 as long as they are not at
increased risk of colorectal cancer and don’t have symptoms of colorectal
cancer (no co-insurance or Part B deductible).
-
Flexible sigmoidoscopy: Covered at no cost* for those age 50 or older (no co-insurance, co-payment,
or Part B deductible) when the test is done for screening. If the test
results in the biopsy or removal of a growth, it’s no longer a “screening”
test, and you will be charged co-insurance and/or a co-pay, although your
deductible will be waved.
-
Colonoscopy: Covered at no cost* at any age (no co-insurance, co-payment, or Part B
deductible) when the test is done for screening. If the test results in
the biopsy or removal of a growth it’s no longer a “screening”
test, and you will be charged co-insurance and/or a co-pay (although you
still don’t have to pay the deductible).
-
Double-contrast barium enema: Beneficiary pays 20% of the Medicare approved amount for the doctor services.
If the test is done in an outpatient hospital department or ambulatory
surgical center, the beneficiary also pays the hospital co-payment.
If you’re getting a screening colonoscopy, contact your insurance
company to confirm how much, if any, you will be expected to pay out of
pocket. This can help you avoid surprise costs. Patients may still have
to pay for the bowel prep kit, anesthesia or sedation, pathology costs,
and facility fee. Patients may get one or more bills for different parts
of the procedure from different practices and hospital providers. Tests
including colonoscopy are not classified by Medicare as screening procedures
if they are done to evaluate specific problems, such as belly (abdominal)
pain, intestinal bleeding, or low red blood cell counts (anemia). If you
are getting a test for such a reason, you may have to pay the usual deductible
and co-pay.
*This service is covered at no cost as long as the doctor accepts assignment
(the amount Medicare pays as the full payment). Doctors that do not accept
assignment are required to tell you up front.
Medicaid coverage for colorectal cancer screening
States are authorized to cover colorectal screening under their Medicaid
programs. But unlike Medicare, there’s no federal assurance that
all state Medicaid programs must cover colorectal cancer screening in
people without symptoms. Medicaid coverage for colorectal cancer screening
varies by state. Some states cover fecal occult blood testing (FOBT),
while others cover colorectal cancer screening if a doctor determines
the test to be medically necessary. In some states, coverage varies according
to which Medicaid managed care plan a person is enrolled in.