Does Medicare pay for a Colonoscopy?

Yes. Colorectal screenings, which include a colonoscopy, are covered by Medicare and private insurers. A colonoscopy is a screening test that helps to detect and remove polyps or precancerous growths.  Medicare colonoscopy coverage renews every 24 months for those at high risk of colorectal cancer and every 180 months for everyone else. This service is open to all ages.

The US Preventive Services Task Force recommends that all 50-year-olds get a colonoscopy. For some doctors, the earlier you get a colonoscopy, the better.

According to the HHS, Medicare spent an estimated $1.3 billion on colonoscopy reimbursement in 2015.

Purpose of colonoscopy

Colonoscopy is a medical process that uses a narrow, lighted tube and a camera to view the colon lining. Doctors perform colonoscopy for a variety of reasons:

• A colonoscopy can detect and possibly remove precancerous polyps. In people who have no symptoms, a screening colonoscopy is performed.
• A diagnostic colonoscopy is done for intestinal symptoms and a need to perform colonoscopy.

With sedation or general anesthesia, the patient is unconscious during the procedure.

How much does it cost?

Several factors determine colonoscopy costs. Some of them are:

• Colonoscopy can be done if the patient is healthy enough at an outpatient surgery center. Hospital colonoscopies are almost always more expensive.
• The anesthetic type. The costs rise when a patient chooses general anesthesia over conscious sedation.
• Geographic area: Costs vary depending on location.
• Tissue sampling: Tissue samples should be collected from a doctor for testing. Tissue sampling equipment and laboratory evaluation may incur higher costs.

Colonoscopy costs, on average, $3,081. Individual health insurance plans usually require patients to have a deductible. It could cost anything from nothing to $1,000 or more.

Colonoscopy under Medicare costs

Medicare has several parts that provide different types of medical services. This section explains how each component covers colonoscopy.

Medicare Part A

The A section of Medicare covers hospital-related expenses. If you need hospital inpatient care, Medicare Part A covers these costs.

At some point, you may need a colonoscopy in the hospital. Imagine you have a GI bleed. Medicare Part A covers these services, and Medicare Part B covers your doctor’s services. However, Medicare may require a copay or deductible for inpatient services. This is a single payment for 60 days in the hospital.

Medicare Part B

Part B covers medical and preventive care and includes outpatient care, such as a colonoscopy. Medicare Part B has a monthly fee and a yearly deductible. The deductible is variable but will be $198 in 2020.

In contrast, Medicare will cover colonoscopies regardless of whether they are used for screening or diagnostic purposes.

Medicare Part C

Medicare Advantage (also known as Part C) combines Parts A and B and prescription drug coverage. The Affordable Care Act requires Medicare Advantage plans to cover colonoscopies.

When choosing a Medicare Advantage plan, the most important consideration is whether the doctor and anesthesia providers are in-network with your Medicare Part C.

Medicare’s Part D

Prescription drug coverage is a supplement to the other parts of Medicare. Medicare Part D plans cover prescriptions for bowel preparation to help clear the colon before a colonoscopy.

Your Medicare Part D plan should include a list of covered and uncovered medications.

Supplemental Medicare plans (Medigap)

Medicare supplement insurance covers out-of-pocket medical expenses. Co-payments and deductibles are included. Regardless of whether you’ve met your deductible, Medicare Part B will cover the cost of a screening colonoscopy. But if a doctor removes polyps or tissue samples, some Medicare supplement insurance plans may be able to help you cover these expenses.

How do you know the costs before Colonoscopy?

Contact your insurance company before your colonoscopy to see how much they will cover.

There are no costs until you have a colonoscopy. Get a quote from your doctor’s office before having a colonoscopy. For all private insurance you may have, you can usually expect an average cost based on Medicare.

Medicare doesn’t cover the cost of colonoscopies, so your doctor’s office must give you an Advance Beneficiary Notice of Noncoverage. Think about whether or not they will sedate you during the procedure. Colonoscopy includes the anesthesia fee in its cost.

If your insurance requires you to see a doctor who is in-network, you may also need to inquire about the anesthesia provider.

Which other variables influence your payments?

The most significant factor that affects your Medicare payments is when your doctor removes polyps or other tissue samples for laboratory review. Since you can’t tell whether you have a polyp or not, your doctor screens you. So, if you have a polyp removed, ask your doctor’s office for an estimate.

You can also contact the US Centers for Medicare & Medicaid Services to access additional information. The hotline is 1-800-633-4227, and the website is Medicare.gov to start.

The Bottom line

A colonoscopy is a necessary test for finding early signs of colorectal cancer.

Medicare covers this procedure for screening purposes, but they consider anesthesia fees and polyp removal charges, so inform your doctor’s office about these costs to budget appointments correctly.

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