Insurance Coverage for Colorectal Cancer Screening

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

The Affordable Care Act (ACA) requires both private insurers and Medicare to cover the costs of colorectal cancer screening tests, because these tests are recommended by the United States Preventive Services Task Force (USPSTF). The law stipulates that there should be no out-of-pocket costs for patients, such as co-pays or deductibles, for these screening tests. But the definition of a "screening" test can sometimes be confusing, as discussed below.

It’s important to note that the USPSTF currently recommends that people at average risk starting screening at age 50, whereas the American Cancer Society now recommends starting at age 45. There’s nothing to stop insurers from covering the tests starting at age 45, and some are likely to do so, but at this time insurers are not required to (and some might not) cover the cost of colorectal cancer screening before age 50.

The ACA doesn’t apply to health plans that were in place before it was passed in 2010, which are called “grandfathered plans.” You can find out if your insurance plan is "grandfathered" by contacting your health insurance company or your employer’s human resources department. Even if you have a "grandfathered plan," 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, which includes a range of test options. In most cases there should be no out-of-pocket costs for these tests, such as co-pays or deductibles.

For people who choose to be screened with colonoscopy

Many people choose to be screened with colonoscopy. While it might not be right for everyone, it can have some advantages, such as only needing to be done once every 10 years. And if the doctor sees something abnormal during the colonoscopy, it can be biopsied or removed at that time, most likely without needing any other test.

Although many private insurance plans cover the costs for colonoscopy as a screening test, you still might be charged for some services. 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. Call your insurer if there’s anything you’re not sure about.

Soon after the ACA became law, some insurance companies considered a colonoscopy to no longer be just a ‘screening’ test if a polyp was removed during the procedure. It would then be a ‘diagnostic’ test, and would therefore be subject to co-pays and deductibles. However, the US Department of Health and Human Services has clarified that removal of a polyp is an integral part of a screening colonoscopy, and therefore patients with private insurance should not have to pay out-of-pocket for it (although this does not apply to Medicare, as discussed below).

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. 

For people who choose to be screened with a different test

Test options other than colonoscopy are also available, and people might choose one of these other tests for a variety of reasons. Again, the screening test itself should be covered, with no out-of-pocket costs such as co-pays or deductibles. But if you have a screening test other than colonoscopy and the result is positive (abnormal), you will need to have a colonoscopy. Some insurers consider this to be a diagnostic (not screening) colonoscopy, so you may have to pay the usual deductible and co-pay.

Before you get a screening test, check with your insurance provider about what it might mean if you need a colonoscopy as a result of the test, and how much (if anything) you should expect to pay for it. 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?

Medicare covers the following tests, generally starting at age 50:

Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) once every 12 months.

Stool DNA test (Cologuard) every 3 years for people 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, but not within 10 years of a previous colonoscopy.

Colonoscopy

  • Once every 2 years for those at high risk (regardless of age)
  • Once 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 who are at high risk
  • Once every 4 years for those 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 insurer.

What would someone on Medicare expect to pay for a colorectal cancer screening test?

  • FOBT/FIT: Covered at no cost* (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* (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. Note: If the test results in the biopsy or removal of a growth, it’s no longer a “screening” test, and you will be charged the 20% co-insurance and/or a co-pay (but you don't have to pay the Part B deductible).
  • Colonoscopy: Covered at no cost* at any age (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. Note: If the test results in the biopsy or removal of a growth, it’s no longer a “screening” test, and you will be charged the 20% co-insurance and/or a co-pay (but you don’t have to pay the deductible).
  • Double-contrast barium enema: You pay 20% of the Medicare approved amount for the doctor services. If the test is done in an outpatient hospital department or ambulatory surgical center, you also pay the hospital co-payment.

If you’re getting a screening colonoscopy (or sigmoidoscopy), be sure to find out how much you might have to pay for it. Also ask how much you will have to pay if a polyp is removed or a biopsy is done. This can help you avoid surprise costs. You may still have to pay for the bowel prep kit, anesthesia or sedation, pathology costs, and facility fee. You may get one or more bills for different parts of the procedure from different practices and hospital providers.

It's important to understand that if you have a screening test other than colonoscopy and the result is positive (abnormal), you will need to have a colonoscopy. This is typically considered a diagnostic (not screening) colonoscopy, so 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 is medically necessary. In some states, coverage varies according to which Medicaid managed care plan a person is enrolled in.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master's-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

US Department of Health and Human Services. Your Medicare Coverage: Colorectal Cancer Screenings. Accessed at www.medicare.gov/coverage/colorectal-cancer-screenings.html on May 15, 2018.

Wolf AM, Fontham ET, Church TR, et al. Colorectal cancer screening for average risk adults: 2018 guideline update from the American Cancer Society. CA: Cancer J Clin. 2018 [Epub ahead of print]. 

Last Medical Review: February 21, 2018 Last Revised: May 30, 2018

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