Do Medicare Advantage plans cover colonoscopies?

March 22, 2021
Aspire Blog - Medicare and Colonoscopies

March is National Colorectal Cancer Awareness Month. Colorectal cancer affects both men and women. According to the Centers for Disease Control and Prevention (CDC), 140,000 people in the U.S. are diagnosed each year, and more than 50,000 people die because of it. They add that risk increases with age – over 90 percent of colorectal cancers occur in people who are 50 years old or older.

There is good news, however. Colon cancer is very treatable when detected early. Right now, colonoscopy is considered the gold standard screening test. There are several screening test options for colon cancer screening. You can talk with your doctor about which is right for you. First and foremost, the most important thing to remember is to get screened.

There are a few questions seniors might have about colon cancer screening, colonoscopies and Medicare coverage. We hope to clear some of these up for you:

1. What are the different types of colorectal cancer screenings and eligibility requirements for each?

The following are Medicare-covered colorectal cancer screening exams (as long as the doctor performing the service accepts Medicare):

  • fecal occult blood test is a lab test used to check stool samples for hidden blood. Original Medicare covers this test every twelve months if you are age 50 and older.
  • screening colonoscopy is covered by Original Medicare as often as every 24 months for those at very at high risk, or once every 10 years if you are not at high risk.  There is no minimum age requirement if medically-indicated by risk.
  • Cologuard is the brand name of a test that you might have seen on television.  It is less invasive than colonoscopy, and is an alternative that your physician might recommend (after discussing the pros and cons with you) if you are at low risk for colon cancer.  If so, it is a Medicare-covered test.
  • flexible sigmoidoscopy is similar to a colonoscopy, but is much less widely recommended because it does not probe your entire colon. If ordered by your physician for a specific accepted indication, will be covered by Medicare.
  • barium enema is an X-ray of the colon after it has been filled with barium. It is generally not used for screening. However, if ordered by your physician for a specific accepted indication, will be covered by Medicare.

Medicare Advantage (MA) plans cover these same colorectal cancer screenings without applying deductibles, copayments or coinsurance as long as you see an in-network provider and meet Medicare’s eligibility requirements for these services.

2. What is a screening colonoscopy?

A screening colonoscopy is used as a preventive measure to screen for colon cancer and related issues, usually starting at a particular age or if you have a family history that makes you “high risk.”

3. What is a diagnostic colonoscopy?

A diagnostic colonoscopy is used when you show specific symptoms that may indicate colon cancer or other issues. These help the physician further diagnose your condition and may involve biopsies, lesion removals, etc.

4. What does a colonoscopy cost with Original Medicare or an MA plan?

Medicare covers colonoscopies differently depending on the purpose. Original Medicare pays the full cost of a screening colonoscopy as long as the provider who performs the procedure accepts Medicare rates. MA plans cover these same costs under similar terms if the provider handling your procedure is in your plan’s network.

It starts to get a little trickier if a polyp is found and removed during the screening colonoscopy — then procedure is considered diagnostic, rather than preventive. If that happens and you have Original Medicare, you will likely owe 20 percent of the Medicare-approved fee (known as co-insurance) though your deductible does not apply. If you get your colonoscopy done in a hospital, you’ll also have to pay a copayment.

If you have an MA plan (like Aspire Health Plan), contact Member Services prior to your scheduled screening colonoscopy to make sure you are aware of any costs should a screening colonoscopy become “diagnostic”. We are happy to walk you through the process.

Original Medicare covers scheduled diagnostic colonoscopies subject to copayments and deductibles. Deductibles and co-pays for diagnostic colonoscopies for MA vary by plan.  Aspire Health Plan members can check the Evidence of Coverage (EOC) for specific information, and if you have any questions, contact Member Services directly using the phone number on the back of your member ID card.


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