Does Medicare Cover Colorectal Cancer Screenings?
Medicare covers five different types of colorectal screening tests, including colonoscopy, FOBT/FIT, Cologuard, flexible sigmoidoscopy and double-contrast barium enema screening tests. The Affordable Care Act requires Medicare to cover all costs associated with colorectal screening in most cases.
What Does Medicare Cover?
Original Medicare — Medicare Part A and Part B — covers an initial, “Welcome to Medicare” preventive physical examination when you first enroll in Medicare. It includes a colorectal screening test that Medicare will pay for.
But as a new beneficiary, you have to take the exam within the first 12 months after enrolling in Medicare. Once you’ve had Medicare Part B medical insurance for more than 12 months, Medicare will pay for an annual wellness visit.
Your doctor will use this yearly wellness visit to create a personalized prevention plan with you and create a screening schedule for future colorectal and other screening tests.
Medicare is required under the Affordable Care Act to pay for most recurrent colorectal screenings, but they have to stick to Medicare’s schedule and certain other Medicare requirements.
Different Colorectal Screening Tests Medicare Covers
Medicare covers five different types of colorectal screenings. The different tests are recommended for different patients based on age, frequency of testing and your risk for colorectal cancer.
In certain cases, you may have out-of-pocket expenses if the screening turns into a biopsy or tissue removal.
|SCREENING TEST||FREQUENCY||HOW MUCH MEDICARE PAYS|
|Fecal occult blood test (FOBT) or fecal immunochemical test (FIT)||Once every 12 months if you are 50 or older||Medicare pays the full cost — you pay no copayment, coinsurance or Medicare Part B deductible.|
|Cologuard (stool DNA test)||Once every three years for people 50 to 85 with no symptoms of or increased risk for colorectal cancer||Medicare pays the full cost — you pay no copayment, coinsurance or Medicare Part B deductible.|
|Flexible sigmoidoscopy||Once every four years, but not within 10 years of a previous colonoscopy||Medicare pays full costs unless the doctor performs a biopsy or removes a growth. In those cases, you have to pay 20 percent copayment, but your Medicare Part B deductible does not apply.|
||Medicare pays full costs unless the doctor performs a biopsy or removes a growth. In those cases, you have to pay 20 percent copayment, but your Medicare Part B deductible does not apply.|
|Double-contrast barium enema||
||Medicare covers 80 percent. You are responsible for a 20 percent copay for doctor’s services. You may also be responsible for hospital copayments or coinsurance. This screening is only covered if your doctor determines it has equal or greater screening value than a colonoscopy or sigmoidoscopy.|
Colonoscopies and sigmoidoscopies are only considered screening tests so long as your doctor is looking for signs of colorectal cancer. If your doctor finds polyps or other growths and biopsies or removes them, the procedure’s become diagnostic tests.
The ACA does not require full coverage for diagnostic tests. That’s why you may have out-of-pocket costs if you have either of these procedures.
It’s important to find out the cost of a colonoscopy, sigmoidoscopy or double-contrast barium enema so you can be prepared for possible out-of-pocket costs.
If you’re getting a colonoscopy or sigmoidoscopy, also ask about the cost of biopsies and polyp removal to prepare for potential expenses.
At What Age Should Colorectal Cancer Screening Begin?
Medicare covers screenings for beneficiaries as young as 50. About 90 percent of colorectal cancer happens in people 50 or older.
The U.S. Centers for Disease Control and Prevention recommends people be routinely screened for colorectal cancer starting at age 50. The American Cancer Society recommends that even people at average risk for colorectal cancer start screenings at 45 — even for people at average risk for developing the disease.
The younger age from the American Cancer Society is in response to an increase in younger people being diagnosed with colorectal cancer. Your doctor may recommend how soon and how often you are screened based on whether you are considered at high risk or at average risk for colorectal cancer.
|AVERAGE RISK||HIGH OR INCREASED RISK|
|Never received radiation cancer treatment focused on the abdomen or pelvic area||Having ever received radiation to treat cancer in the abdomen or pelvic area|
|No family history of colorectal cancer||A family history of colorectal cancer|
|No confirmed or suspected hereditary colorectal cancer condition (Lynch syndrome or FAP)||A family history of hereditary colorectal cancer conditions|
|No history of colorectal cancer or certain types of polyps||Having a personal history of colorectal cancer or certain types of polyps in the past|
|No history of inflammatory bowel disease (ulcerative colitis, Crohn's disease)||Having a personal history of inflammatory bowel disease|
Federal agencies and the American Cancer Society recommend screenings continue until you are 75, so long as you have more than 10 years of life expectancy. After that, you should be screened based on your preferences and can stop screenings at 85, according to the American Cancer Society.
What Does a Colorectal Screening Involve?
Colorectal cancer screenings can be as simple as a test kit you take home and mail into a lab or complicated enough that they need to be performed in a health care facility with anesthetics and a medical team.
- Fecal Occult Blood Test (FOBT)
- FOBT screenings use a chemical to test for blood in your stool. Your doctor will give you a test kit with which you will gather a small sample of your stool which you send off to your doctor or a lab to be checked.
- Fecal Immunochemical Test (FIT)
- A FIT screening is also done with a test kit you send off. There are two versions. The standard test requires you to gather a small sample as with the FOBT kit and uses antibodies to detect blood in your stool. A FIT-DNA test requires you to collect a complete stool sample and send it off to a lab that checks for cancer cells.
- Flexible Sigmoidoscopy
- A doctor inserts a thin, flexible tube into your rectum. The device has a light and camera mounted at the end that allows the doctor to look for polyps or other signs of cancer in the lower third of your colon.
- Similar to a flexible sigmoidoscopy, but the tube is longer. A colonoscopy allows your doctor to check for polyps or other signs of cancer through the entire length of your colon.
- Double-Contrast Barium Enema
- You will be required to completely empty your colon and will undergo an X-ray to make sure your colon is completely clean. A radiologist will then insert a tube into your rectum to deliver barium — a metallic substance that will coat the interior of your colon to give doctors a clear image of potential cancer on a second series of X-rays.
There are several factors that go into determining which test is best for your situation.
- Your preferences
- Your condition
- How likely you are to get the test
- What resources are available for testing and follow-up
You should talk to your doctor about the pros and cons of each test, ask about costs Medicare covers and potential costs you may have to pay out of pocket. You should also find out how often you will need to be tested depending on which colorectal screening test you receive.
9 Cited Research Articles
- U.S. Centers for Disease Control and Prevention. (2021, February 8). What Should I Know About Screening? Retrieved from https://www.cdc.gov/cancer/colorectal/basic_info/screening/index.htm
- U.S. Centers for Disease Control and Prevention. (2021, February 8). Colorectal Cancer Screening Tests. Retrieved from https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm
- Mayo Clinic. (2020, December 5). Colon Cancer Screening: Weighing the Options. Retrieved from https://www.mayoclinic.org/diseases-conditions/colon-cancer/in-depth/colon-cancer-screening/art-20046825
- American Cancer Society. (2020, November 17). American Cancer Society Guideline For Colorectal Cancer Screening. Retrieved from https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html
- DePietro, M. (2020, September 30). What Coverage Does Medicare Provide for Colorectal Cancer? Retrieved from https://www.medicalnewstoday.com/articles/does-medicare-cover-colorectal-cancer
- American Cancer Society. (2020, June 29). Insurance Coverage for Colorectal Cancer Screening. Retrieved from https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/screening-coverage-laws.html
- American Society of Clinical Oncology. (2019, October). Colorectal Cancer: Screening. Retrieved from https://www.cancer.net/cancer-types/colorectal-cancer/screening
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Colonoscopies. Retrieved from https://www.medicare.gov/coverage/colonoscopies
- Mayo Clinic. (n.d.). Barium Enema. Retrieved from https://www.mayoclinic.org/tests-procedures/barium-enema/about/pac-20393008