Ask a Healthcare Provider Your Colon Health Question Now

Will Medicare / Medicaid Cover a Colonoscopy?

Table of Contents

    Screening colonoscopies are pivotal in helping people with early stage colorectal cancer catch the disease at its most curable point. However, a colonoscopy can be quite expensive, especially if polyps (abnormal tissue that may be precancerous) are found. Many people with limited incomes and resources neglect to get a colonoscopy due to the cost, not knowing that there are government programs available that completely cover the cost of a screening colonoscopy. 

    The Affordable Care Act compels private insurers and Medicare to cover all costs related to colorectal cancer screenings. If you have Medicare, your screening colonoscopy will be completely covered

    The Affordable Care Act compels private insurers and Medicare to cover all costs related to colorectal cancer screenings. This means that if you have Medicare, your screening colonoscopy will be completely covered under certain conditions with no out-of-pocket costs like a deductible or co-pay. However, you may need to pay for certain procedures during a colonoscopy, like a polyp removal or biopsy, which changes your screening colonoscopy to a diagnostic procedure. This can be confusing for many Medicare or Medicaid patients awaiting a colonoscopy. In this article, you will learn about the specific costs Medicare and Medicare will cover in a colonoscopy to help clarify any confusion you may be having. 

    Medicare and Medicaid Overview

    Medicare and Medicaid are government run medical programs that offer people who qualify health insurance and assistance with paying medical bills. Medicare is a federal health insurance program for people over the age of 65, disabled people, and patients who have end-stage renal disease..You become eligible for Medicare when you pay money into trust funds over time. Most people are enrolled in Medicare through the Social Security Administration and do not have to enroll. Patients who are over the age of 65 are eligible for free hospital insurance through Medicare because they have paid taxes for a certain period of time. Medical insurance through Medicare is also available, but for a monthly premium.Information about Medicare is available at Medicare here

    Medicaid is more of an assistance program that serves low-income people of all ages.People with Medicaid usually do not have to pay any medical-related costs and sometimes have to pay a small co-payment. The program is run by local and state governments under federal guidelines. If you have Medicaid, payments for services are paid directly to your healthcare provider. Pregnant women, children, teenagers, and all people who have limited income and resources can apply and are usually eligible for Medicaid. People who have extremely high medical bills that they cannot pay may also qualify for Medicaid. Each state has its own guidelines regarding who is eligible and what services you receive. If you are concerned about medical bills and wonder if you are eligible in your state, visit Medicaid here

    Medicare Colonoscopy Coverage

    The Centers for Disease Control and Prevention and the US Preventive Services Task Force (USPSTF) support health authorities in their goal to screen at least 80% of people ages 50-75 for colorectal cancer by 2024. This means that at least 20 million people need to be screened for colorectal cancer per year with the preferred method being a colonoscopy. Despite the drive to screen for colon cancer, millions of people are not getting the recommended procedure. 

    If you are on Medicare and are awaiting a screening colonoscopy, be sure to choose a physician that agrees to the rate that Medicare pays for the procedure. This is referred to as an “accepted assignment”. Once your physician accepts the assignment you typically should not have to pay any costs for the procedure itself. 

    The cost of the colonoscopy is a deterring factor for many people who have limited income and resources and that’s where Medicare comes in. 

    Medicare will cover the entire cost of your colonoscopy if it is considered a screening colonoscopy. Your colonoscopy is a screening colonoscopy if you are:

    • Between 50-75 years of age
    • Have no prior history of polyps or colon cancer
    • Have no gastrointestinal (GI) symptoms prior to colonoscopy

    Your colonoscopy is considered a diagnostic colonoscopy for the following reasons:

    • You have a personal history of polyps or colorectal cancer
    • You have lower GI symptoms, such as bleeding, anemia, diarrhea, and constipation
    • A polyp or abnormal tissue is found during the screening colonoscopy

    If you are on Medicare and are awaiting a screening colonoscopy, be sure to choose a physician that agrees to the rate that Medicare pays for the procedure. This is referred to as an “accepted assignment”. Once your physician accepts the assignment you typically should not have to pay any costs for the procedure itself. 

    Medicare will cover your colonoscopy every 2 years if you are at an elevated risk for colorectal cancer. Those not at a high risk for colorectal cancer are covered every 10 years. Your colonoscopy is completely covered by Medicare (if your doctor accepts Medicare) unless there is a polyp or abnormal tissue found and removed during the procedure. In these cases, you may have to pay 20% of the total cost owed to your doctor and a copayment to the hospital if done there. 

    Medicaid Colonoscopy Coverage

    Medicaid is essentially a medical funding program that is run by the state and the determination of whether your colonoscopy is covered is dependent upon if your state approves. States are able to cover these screenings, but there is no assurance that you can get a free colonoscopy for a cancer screening. In other words, the funding varies from state to state and you will need to contact Medicaid to see if your colonoscopy will be covered. In most cases, the screening is authorized and you will be able to get the procedure at no cost to you.

    Other Government Programs

    Colorectal cancer is the second leading cause of deaths due to cancer in the United States. Screening for colorectal cancer is the best way to detect colorectal cancer at its earliest and most treatable stage. In 2018, 21.7 million people aged 50 to 75 in the United States have never been screened for colorectal cancer.

    Colorectal cancer is the second leading cause of deaths due to cancer in the United States. Screening for colorectal cancer is the best way to detect colorectal cancer at its earliest and most treatable stage. In 2018, 21.7 million people aged 50 to 75 in the United States have never been screened for colorectal cancer. The people who are not screened are at a much higher risk for developing colorectal cancer. 

    Groups who are prone to not get a colonoscopy include:

    • Hispanics
    • American Indians and Alaska Natives
    • Rural populations
    • Lower income populations
    • Men

    There are government programs that were created to get as many people screened as possible, especially those who are less likely to screen for colon cancer. There are several evidence-based programs in the United States that reach out to the underserved populations. These include:

    • Colorectal Cancer Control Program
    • Against Colorectal Cancer in Our Neighborhoods
    • Colorectal Cancer Education, Screening, and Prevention Program
    • Colorectal Cancer Screening in Chinese Americans Project
    • Colorectal Cancer Screening Intervention Program
    • El Proyecto de Salud Colorectal 
    • Kukui Ahi (Light the Way): Patient Navigation
    • Targeting Cancer in Blacks (TCiB)

    The National Institutes of Health has a web page devoted to giving information and access to these programs. If you are interested follow this link here.

    References


    Gates, A., Ranji, U., & Snyder, L. (2014, November 13). Coverage of preventative services for adults in Medicaid. Retrieved from KFF:
    https://www.kff.org/report-section/coverage-of-preventive-services-for-adults-in-medicaid-survey-findings/

    Joseph, D. (2016). Colorectal cancer screening: Estimated future colonoscopy need and current volume and capacity: Colonoscopy Need and Capacity. Cancer. Retrieved from ResearchGate: https://www.researchgate.net/publication/303405794_Colorectal_cancer_screening_Estimated_future_colonoscopy_need_and_current_volume_and_capacity_Colonoscopy_Need_and_Capacity

    Medicare Writing Staff. (2021). Colonoscopies. Retrieved from Medicare.gov: https://www.medicare.gov/coverage/colonoscopies

    Nall, R. (2019, December 12). Is colonoscopy covered by Medicare? Retrieved from Healthline:
    https://www.healthline.com/health/medicare/does-medicare-cover-colonoscopy

    National Cancer Institute. Colorectal cancer screening evidence-based programs listing. Retrieved from NIH:
    https://ebccp.cancercontrol.cancer.gov/topicPrograms.do?topicId=102265&choice=default

    Ask A Question