Is Colonoscopy Covered By Medicare?
Medicare pays for colonoscopies. Yes, it does. But not all of them.
And if they don’t, then why do so many people get one? Why do some doctors insist on getting their patients into the procedure when there’s no guarantee that it will save money down the road?
The answer lies in a little-known provision in the Affordable Care Act (ACA). That provision, which was signed into law in 2010, says that any “covered outpatient” — or anyone who gets treatment from a doctor but isn’t hospitalized — can receive a colonoscopy free of charge through Medicare.
That means your insurance company won’t have to foot the bill; you’ll just pay out of pocket. There’s no limit on how much you might owe.
If you’re eligible for the program, your insurer may even offer to pick up part of the tab.
But that doesn’t mean everyone qualifies. To qualify, you must meet certain criteria: You must be at least 55 years old; you need to see a primary care physician within the past 12 months; and you live in a state where the procedure is available.
(If you live outside those states, your coverage may still provide coverage. Call your state’s Medicaid office to find out more.)
Why the extra age restriction?
Well, that’s because Medicare has a rule that anyone between the ages of 55 and 64 must receive preventative care. If you’re in this age range, you need to get a physical every year, and one way to do it is with a colonoscopy (as well as other preventative measures, like getting vaccines and screening tests).
But why the issue with the location?
The reason is that the colonoscopy provision is only available in certain states. In fact, as of 2016, there are only 17 states where this is covered.
If you live in a state where it isn’t provided, you can still get a free screening colonoscopy through the National Colorectal Cancer Roundtable Association (NCCRA), but you’ll have to pay out of pocket if you’re under 55. If you’re over that age, however, you’ll still be able to receive the preventative measure from your primary physician at no cost (as long as you live in a state where it’s covered).
As you can see, there are a lot of stipulations about who can qualify for free colonoscopies. But if you’re concerned about your health and want to get one, you should talk to your doctor to see if you qualify.
Does Medicare Cover Colonoscopies?
What You Need to Know
If you need a colonoscopy in the next year, you might be wondering: Is colonoscopy covered by medicare?
As it turns out, it depends on your age and where you live. In most cases, however, the procedure is not covered by the government program.
If you’re under the age of 55 and live in a state that doesn’t offer this preventative measure, then you could be looking at quite the hefty bill if you don’t have insurance. If you do have insurance and your plan covers preventative measures like colonoscopies and other cancer screenings, then it should pick up the cost.
If you’re over the age of 55 and live in a state that offers preventative care, then you may be able to get a free colonoscopy. Again, this all hinges on whether you have insurance, your plan and where you live.
You can find out more information by contacting your state’s Medicaid office.
Although Medicare won’t cover most preventative measures for colonoscopies, it will cover the procedure if a patient is experiencing symptoms.
What Are the Age Requirements for Medicare Coverage?
When it comes to in-network coverage, you might be wondering: Is colonoscopy covered by Medicare?
Well, it depends on your age, as well as the symptoms you’re experiencing.
If you’re over the age of 65 and have symptoms of a disorder that should be caught during a colonoscopy, then the procedure may be covered by Medicare.
For example, if you’re over the age of 65 and have rectal bleeding or have a family history of colon cancer, your doctor may send you for a colonoscopy to rule out any potential issues. If you’re diagnosed with an issue that could’ve been ruled out during a preventative colonoscopy, Medicare will pick up the cost of the procedure (as well as any treatment that follows).
What’s the Cost of a Colonoscopy?
Sources & references used in this article:
Barriers to colorectal cancer screening among Medicare consumers by CN Klabunde, AP Schenck, WW Davis – American journal of preventive …, 2006 – Elsevier
Trends in colorectal cancer test use in the medicare population, 1998–2005 by AP Schenck, SC Peacock, CN Klabunde… – American journal of …, 2009 – Elsevier
Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly? by YCT Shih, L Zhao, LS Elting – Health Affairs, 2006 – healthaffairs.org
Measuring breast, colorectal, and prostate cancer screening with Medicare claims data by JL Freeman, CN Klabunde, N Schussler, JL Warren… – Medical care, 2002 – JSTOR
Lifetime and treatment-phase costs associated with colorectal cancer: evidence from SEER-Medicare data by K Lang, LM Lines, DW Lee, JR Korn, CC Earle… – Clinical …, 2009 – Elsevier
Medicare cost of colorectal cancer screening: CT colonography vs. optical colonoscopy by B Pyenson, PJ Pickhardt, TG Sawhney, M Berrios – Abdominal imaging, 2015 – Springer