A colonoscopy is an important exam that can help detect health problems while they are still highly treatable. Doctors can detect and remove polyps before they have a chance to grow or become cancerous.
Does Medicare cover colonoscopies? How much do they cost? This page will help answer common questions about Medicare coverage and this essential exam.
Medicare Part B will cover a colonoscopy regularly, depending on your needs and risk factors. If you’re considered at high risk for colon cancer, Medicare will cover the exam every two years.
However, if you have a normal or low risk of colon cancer, Medicare covers a colonoscopy every 10 years. There’s no minimum age requirement to get coverage for a colonoscopy, although doctors often recommend the exam for those 50 and over.
For most medical care under Medicare Part B, you’re responsible for your annual deductible and a copayment. However, a colonoscopy exam is different. It’s considered preventive care, so your deductible does not apply.
If the doctor accepts the Medicare assignment, you don’t pay anything for the colonoscopy exam. However, if a polyp is found and has to be removed, the exam moves from being preventive to diagnostic. As a result, you may be billed for your normal Medicare Part B coinsurance, which is 20% of the Medicare-approved amount for the procedure.
If you’re curious about how much your test and potential polyp removal will cost, be sure to talk to your doctor. Factors such as whether the provider accepts the Medicare assignment, how much the doctor charges and more may impact your out-of-pocket costs.
Colonoscopy prep involves taking specific medication to clear your system, allowing the exam to be completed. Medicare Part B does not cover the medication. However, if you have Medicare Part D for prescription coverage, the prep kit should be covered with your normal Part D deductible and copayment.
If you have Medicare Part C, or Medicare Advantage, drug coverage is often included with the plan. In general, colonoscopy prep kits are covered under Medicare Advantage drug plans. However, you might have a deductible or copayment.
Most people don’t experience a colonoscopy while awake. Instead, they are put under anesthesia for the exam. The anesthesia used for a colonoscopy is covered under Medicare Part B, along with other relevant costs for the procedure.
Your out-of-pocket expenses will still be $0 if the test is preventive, and you’ll still pay 20% of the allowed costs for all aspects of the procedure, including anesthesia if polyps are found and removed.
Many insurance plans require pre-authorization before they will cover a medical service. In general, Original Medicare does not require pre-authorization for a colonoscopy.
However, your Medicare Part D plan might require pre-authorization for the colonoscopy prep kit before you obtain it, so be sure to check with your specific plan. Also, if you have a Medicare Advantage plan, you will likely need prior authorization before you move forward with your exam.
Because a colonoscopy is very routine, it’s unlikely that you will have any trouble getting the authorization you need. To avoid headaches, be sure to check with your insurance company before moving forward if you have a Medicare Advantage plan.
If you have more questions about how colonoscopies are covered by Medicare or want to compare different Medicare coverage options, we’re here to help. Simply contact us to talk to a licensed agent today!