Colorectal Cancer Prevention and Early Detection

+ -Text Size

TOPICS

Colorectal cancer screening: Insurance coverage

The American Cancer Society believes that all people should have access to cancer screenings, without regard to health insurance coverage. Limitations on coverage should not keep someone from the benefits of early detection of cancer. The Society supports policies that give all people access to and coverage of early detection tests for cancer. Such policies should be age- and risk-appropriate and based on current scientific evidence as outlined in the American Cancer Society’s early detection guidelines.

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 (where the procedure is done). Review your health insurance plan for specific details, including if your doctor is on your insurance company’s list of “in-network” providers. If the doctor is not in the plan’s network, you may have to pay more out-of-pocket.

Colonoscopies that are done to evaluate specific problems, such as belly (abdominal) pain, intestinal bleeding, or low red blood cell counts (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 how much (if anything) you should expect to pay for it. 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:

  • Once every 2 years for those 50 years and older who are at high risk
  • Once every 4 years for those 50 years and older who are at average risk

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 is waived).
  • 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, be sure to find out how much you might have to pay for it. 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.


Last Medical Review: 10/15/2014
Last Revised: 02/01/2016