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According to the National Cancer Institute, colon cancer is the third most common cancer among both men and women in the United States. However, nearly 30% of adults ages 50 – 75 have never been screened for colon cancer. Considering how effective colonoscopies can be in detecting colon cancer early, it’s surprising that over 20 million older adults haven’t ever received this type or any colon cancer screening.
It’s also surprising that so many older adults in the United States haven’t had a colonoscopy performed, considering Medicare covers them at 100%. While Medicare doesn’t cover screening colonoscopies annually at 100%, your doctor may be able to request more frequent screenings depending on your risk level for colon cancer. Medicare covers other types of colon cancer screenings as well.
In most cases, you’ll pay nothing for your Medicare-covered colonoscopy. However, there are some cases where there is a possibility of you having some cost-sharing expenses. Also, depending on the type of screening, the part of Medicare that covers it can vary.
Colon cancer also called colorectal cancer, is a type of cancer located in the digestive tract’s lower end. Abnormal cells multiply at a rapid rate that can eventually form a cancerous tumor. If caught early, colon cancer is generally treatable.
While colon cancer doesn’t discriminate by age, older adults are more likely to develop colon cancer than younger adults. Other risk factors include, but are not limited to:
If Medicare and your doctor consider you a high risk for developing colon cancer, Medicare will cover your colonoscopy more often. According to the Centers for Medicare and Medicaid Services, you are considered high risk if you have any of the following:
Routine screenings for colon cancer are important because early detection of colon cancer allows for a more successful treatment. According to the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC), Older adults aged 50-75 should be screened regularly. How often you’re screened will depend on your doctor’s recommendations and the type of screening you get.
The four most common colon cancer screenings are colonoscopies, sigmoidoscopies, fecal occult blood tests (FOBT), and multi-target stool DNA tests. Out of these three screenings, a colonoscopy is the least frequent type of screening, recommended every ten years, whereas a fecal occult blood test is recommended every year. Your doctor may recommend one or multiple screenings, depending on your history.
Medicare covers these colon cancer screenings and others when they are requested by a doctor who accepts Medicare. If your doctor accepts Medicare assignment and you have had a screening within the restricted time frame, then Medicare will generally cover these tests at 100%.
Medicare Part B covers at-home stool DNA tests every three years for Medicare beneficiaries ages 50-85 who show no symptoms of colorectal cancer and are at average risk for developing colorectal cancer. A common multi-target stool DNA test that Medicare covers is the Cologuard™ test.
Colorectal cancer symptoms include lower gastrointestinal pain, bloody stool, and a positive guaiac fecal occult blood test. You’re considered at average risk for developing colorectal cancer if you don’t have a personal or family history of IBD, adenomatous polyps, or colorectal cancer.
If you meet the requirements and the facility you send your test to accepts Medicare assignment, then Medicare should cover your at-home test at 100%.
Medicare covers FOBTs once a year for Medicare beneficiaries over 50 if recommended by your doctor. Medicare covers these annual tests at 100% if your doctor who performs the test accepts Medicare assignment.
Medicare covers flexible sigmoidoscopies every four years for Medicare beneficiaries over 50. However, if you’ve had a colonoscopy recently and aren’t at high risk for colon cancer, Medicare won’t cover a sigmoidoscopy until ten years after the previous colonoscopy. If your doctor accepts Medicare assignment, Medicare should cover your screening at 100%. However, if you need a biopsy or lesion removal during the same visit, you may be responsible for your Part B coinsurance.
Medicare covers screening colonoscopies every two years for Medicare beneficiaries of any age at high risk of developing colon cancer. However, if you aren’t at high risk, Medicare only covers the screening every ten years. If you have had a flexible sigmoidoscopy over four years ago and haven’t had a colonoscopy in the past ten years, Medicare will cover a screening colonoscopy.
If your doctor accepts Medicare assignment, then Medicare should cover your screening at 100%. However, like sigmoidoscopies, you may be responsible for your Part B coinsurance if a biopsy or lesion removal is done during the same visit.
Doctors and facilities can accept Medicare with or without accepting Medicare assignment. Therefore, there are three types of doctors, those who accept Medicare and accept Medicare assignment, those who accept Medicare but do NOT accept Medicare assignment, and those who don’t accept Medicare at all.
If you see a doctor or go to a facility that accepts Medicare but doesn’t accept Medicare assignment, you could be responsible for Part B excess charges.
Part B excess charges equal up to 15% of the Medicare-approved rate of service. For example, if Medicare approves your colonoscopy at 100% coverage, but a doctor who doesn’t accept Medicare assignment performs your colonoscopy, you could pay 15% of Medicare’s approved rate instead of paying nothing. If Medicare’s approved rate for a colonoscopy is $2,000, you could be left with a $300 bill in this scenario.
However, if you have a comprehensive Medigap plan, such as Plan G, you wouldn’t have to worry about your Part B coinsurance or Part B excess charges as Medigap Plan G covers both costs. Instead, your colonoscopy would be 100% covered regardless of the type of doctor you see.
If you have a Medicare Advantage plan, make sure to see doctors and use in-network facilities with your plan for the most cost-effective prices.
If your doctor recommends a colonoscopy, they will likely prescribe you a prep kit in liquid or pill form. This prep kit is meant to clear out your digestive tract so the doctor has an unobstructed field of view during your colonoscopy.
If your doctor prescribes you a colonoscopy prep kit, you must have it filled at a pharmacy and billed under your Part D drug plan. Colonoscopy prep kits are not covered under Part B. You can check your Part D drug formulary to see which types of colonoscopy prep kits your plan covers.
For example, Suprep, a liquid solution bowel prep kit often used for colonoscopies, may be covered under your Part D plan. Prep kits, like Suprep, will likely be subject to your Part D plan’s deductible. So, if you haven’t met your deductible for the year, you could pay the full price for your prep kit.
The price of the kit ultimately depends on your plan and the brand of kit, but for example purposes, Suprep may cost around $100 before your deductible. If you’ve met your deductible, you would only pay your Part D coinsurance for whichever tier the prep kit falls under.
Our Client Service Team manager tells us that most of the out-of-pocket expenses that surprise people regarding their colonoscopies are related to the prep kit.
It might seem silly for a drug prescribed for a preventative Part B service not to be covered by Part B 100%, but it’s not. This is because you are filling the prescription at the pharmacy and giving it to yourself at home. Remember Part D plans cover drugs you administer to yourself, whereas Part B drugs are given to you by a physician or in a facility. This means if you have a colonoscopy and are put to sleep, Part B will cover that.
Due to the various rules and requirements for each covered colon cancer screening, billing for a colonoscopy can get tricky
Lately, some clients have called in because Part B didn’t cover their colonoscopy prep kit. Our team has had to explain to them that this falls under Part D. We’ve also had callers with Plan N who called because Medicare didn’t cover their colonoscopy at 100% like they expected it would, and it turned out they had used providers that don’t accept assignment. This results in the kind of costs we described above.
