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Colorectal cancer is the 3rd most common cancer in both men and women in the United States. But it’s very treatable when it’s caught early. That’s what makes colonoscopies an important part of your regular health care, helping to find and prevent serious problems.

A colonoscopy is a medical exam that uses a camera attached to a flexible tube to view the inside of the colon (large intestine) and the rectum. This camera, called a colonoscope, scans for abnormalities and diseases, like cancer and polyps. Medicare covers these screenings once every 24 months if you’re at high risk for colorectal cancer.

Original Medicare is divided into separate parts that cover different services. Part A (hospital insurance) covers hospital stays and home health care. Part B (medical insurance) pays for doctor visits, outpatient care and some preventive services. Colonoscopies are included in your Part B benefits. Medicare Advantage (Part C) plans are private, Medicare-approved plans that will also pay for colonoscopies. Let’s take a closer look at what you need to know about Medicare and colonoscopies.

How Often Should I Get a Colonoscopy?

How often you should get a colonoscopy depends on a lot of different things. Your age, medical history and possible risk factors will all be considered. In general:

  • A colonoscopy is recommended every 10 years for people with an average risk of colorectal cancer.
  • People with a family history of colon cancer or who have other risk factors should start screenings earlier or have them more often.

After your first colonoscopy, your doctor or healthcare provider will advise you on when to schedule your next one based on your overall health and individual history. Risk factors also need to be taken into account when considering how often you should get a colonoscopy. They include:

  • A personal history of colorectal cancer.
  • A close relative, including a parent or sibling, with colorectal cancer.
  • A family history of diseases linked to colorectal cancer, such as polyps or Lynch syndrome.

Does Medicare Cover a Colonoscopy?

Medicare considers a colonoscopy as preventive care, which is covered with Medicare Part B. If you’re at a higher risk of colorectal cancer, Medicare will pay the full cost of a colonoscopy every 24 months. If you aren’t at a high risk, Medicare will cover the test once every 10 years (120 months), or 48 months after a previous flexible sigmoidoscopy.

There's no minimum age requirement. If you're not seen as having a high risk but you have health issues connected to colorectal cancer, you'll need a special test to find out more. Medicare will help pay for 80% of the cost of this diagnostic colonoscopy and you’ll need to pay the remaining 20%. And if you first had a non-invasive stool-based screening test (also called a fecal occult blood test or multi-target stool DNA test) and receive a positive result, Medicare will also cover a follow-up colonoscopy. A Wellcare Medicare Advantage plan will also pay for a preventive colonoscopy and may offer additional coverage for diagnostic colonoscopies. Contact us today for more information and to explore your options.

How Often Does Medicare Pay for a Colonoscopy?

How often Medicare helps with colonoscopy costs depends on your health and how likely you are to have colorectal cancer. Usually, Medicare will help pay for a colonoscopy every 10 years if you have an average risk of getting this cancer. But if you have a higher risk of getting it because of your health or family history, Medicare might pay for the colonoscopy more often. In some cases, if polyps or other abnormalities are found during a screening colonoscopy, it may be reclassified as a diagnostic or therapeutic procedure. This could change how Medicare helps with the cost.

How Much Will I Have to Pay for a Colonoscopy?

You won't have to pay for a screening, but not all colonoscopies are free. For example, if your doctor finds and removes a polyp or other tissue during the colonoscopy, you'll pay 15% of the Medicare-Approved Amount for your doctors' services. In a hospital outpatient setting or ambulatory surgical center, you will also pay the facility a 15% coinsurance amount. The Part B deductible doesn't apply. The total amount of money you’ll owe may depend on several things, like:

  • Other insurance you may have.
  • How much your doctor charges.
  • If your doctor accepts assignment.
  • The type of facility.
  • Where you get your test, item, or service.

To learn more about specific costs based on your needs, talk to your doctor or healthcare provider. Colonoscopies are important for our health, especially as we get older. They help find and stop colorectal cancer and can find problems before they become serious. Making them a part of your regular healthcare can help you stay well and live a longer, better life.

Frequently Asked Questions

Do I need a referral for a colonoscopy with Medicare?

In general, Medicare doesn’t require a referral for a colonoscopy screening as long as you meet the eligibility requirements.

How long is the waiting list for a colonoscopy?

The wait time to get a colonoscopy can vary and depends on things like where you live or urgency due to your symptoms and risk factors.

Which Medicare Advantage Plan is right for you?

Call us today to learn more and enroll.

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Disclaimers
Sources
American Cancer Society - Colorectal Cancer Key Statistics
Medicare.gov - Colonoscopies

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Y0020_WCM_134133E Last Updated On: 2/20/2024