Colorectal cancer is the third leading cancer diagnosis and cause of cancer-related death for men and women.1 The American Cancer Society estimates that nearly 150,000 people will be diagnosed with colon or rectal cancer in 2020,2 and that 53,000 will die from it. Death rates have been dropping for decades, in part because of better and more widely available screening.
What You Need to Know
Medicare covers regular colonoscopies, but the frequency varies depending if you are high or low risk.
What you pay out of pocket for a colonoscopy depends on what is found.
Medicare pays for other colon cancer screenings, but the rules differ on when you can get them and what, if anything, you will pay.
What Is Colon or Colorectal Cancer?
Colorectal cancer, also known as colon or rectal cancer, is any cancer that starts in the colon or the rectum. Like other cancers, colorectal cancer begins when a group of cells in the body grow out of control.
What Is a Colonoscopy?
A colonoscopy is a procedure to examine the large colon and rectum for changes or abnormalities using a long tube inserted into the rectum.3 Through an attached camera, the doctor can look inside the colon and, if necessary, remove polyps or take a sample of abnormal tissues.
Colonoscopies are generally recommended every 10 years for people over age 50 with no other risk factors, and more often for those who have additional risk factors or develop pain or other symptoms.4
How Does Colon Cancer Develop?
Colon cancer begins in the large intestine, usually with polyps, or growths, on the inner lining of the colon. Most polyps are not cancerous,5 and fewer than 10% develop into invasive cancer.6 The risk increases with age and other factors like lifestyle (meaning your diet, weight, and exercise level, as well as your tobacco or alcohol use), personal or family medical history, and certain genetic conditions.
Often, people have no symptoms, making screening especially important. Consult a doctor if you think you’re experiencing symptoms.7
How Frequently Does Medicare Cover Colonoscopies?
Medicare covers colonoscopies for screening purposes once every 24 months for high-risk enrollees or once every 120 months for people at average risk.8
Are There Different Types of Colonoscopy Coverage?
Medicare covers colonoscopies differently if the purpose is preventive or diagnostic.
Preventive or screening colonoscopies are performed based on your age, gender, or general medical or family history. By definition, you get a screening colonoscopy when you have no specific reason to believe you have colon cancer.
A diagnostic colonoscopy is performed if you have symptoms or previous abnormal findings. If your doctor finds polyps or abnormal tissue during a screening colonoscopy, the test converts to a diagnostic colonoscopy under Medicare rules.
If It Is a Preventive Screening and You Are High Risk
Medicare covers a screening colonoscopy once every 24 months for people considered high risk,9 defined as having a history or a close relative with a history of colorectal polyps or cancer, a history of polyps, or inflammatory bowel disease like Crohn’s disease or ulcerative colitis.10
If It Is a Preventive Screening and You Are Not High Risk
For people considered average risk, where your only risk factor is your age, Medicare covers a preventive colonoscopy every 120 months.
If It Is a Diagnostic Screening
Medicare covers diagnostic colonoscopies subject to copayments and deductibles. If a screening colonoscopy converts to a diagnostic procedure, you’ll be responsible for a copayment but not the deductible.
How Much Does a Colonoscopy Cost with Medicare?
If It Is a Preventive Screening
If you get your preventive colonoscopy from a healthcare provider who participates with Medicare and has agreed to accept assignment for Medicare-covered services, you’ll pay no copayment or deductible.11 Accepting assignment means that the provider agrees or is required by law to accept Medicare-approved amounts as payment in full. Most doctors who accept Medicare accept these payment terms, but it’s a good idea to confirm before you get services.
If It Is a Diagnostic Screening
If your doctor finds and removes a polyp or other tissue during your colonoscopy, Medicare considers it diagnostic,12 even if you went in for a preventive screening. For diagnostic colonoscopies, you may pay coinsurance — 20% of the bill — plus a copayment if you get your colonoscopy in a hospital. Your Part B deductible does not apply.
What Other Exams Screen for Colon Cancer?
There are multiple colorectal cancer screening tests.13
Fecal occult blood test (FOBT) or fecal immunochemical test (FIT)
The U.S. Preventive Services Task Force deems several types of stool tests acceptable for colorectal cancer screening.16
A fecal occult blood test (FOBT) uses a chemical to measure blood in stool or feces, which can be a sign of polyps or colorectal cancer.
A fecal immunochemical test (FIT) uses antibodies to detect hemoglobin protein in stool or feces. FITs are more sensitive than FOBTs.17
Stool DNA test
A FIT-DNA or stool DNA test detects hemoglobin as well as biomarkers for cancer from the lining of the colon and rectum. These tests are more sensitive than standard FITs, so they detect more abnormalities but also more false-positives.
Flexible sigmoidoscopy inserts a lighted tube with viewing lens into the sigmoid colon through the rectum.18 Abnormal cells or growths can be removed for biopsy. Unlike colonoscopy, this test does not usually require sedation.
Double-contrast barium enema
A double-contrast barium enema offers another way to visualize the colon from outside the body.19 Using a series of x-rays, this test is less invasive, appropriate for people who cannot undergo a colonoscopy.
Does Medicare Cover These Screenings?
FOBT and FIT tests are covered every 12 months for enrollees 50 or older with a referral from your doctor or other qualified healthcare provider. If the doctor conducting the test accepts assignment — or Medicare-approved payment — you pay nothing.
At-home, multi-target stool DNA tests are covered once every three years if you’re between age 50 and 85,22 at average risk, and showing no symptoms. If you’re eligible, you pay nothing for the test if it’s performed by a provider who accepts Medicare assignment.
Flexible sigmoidoscopies are covered once every 48 months for most people aged 50 and older, or 120 months after a previous screening colonoscopy.23 If your doctor accepts assignment, you pay nothing. If this screening turns into a biopsy or removal of tissue, the procedure converts to a diagnostic test and your copayment or coinsurance will apply. However, the Part B deductible does not.
Double-contrast barium enemas are covered through Medicare Part B for enrollees age 50 and older once every 48 months in place of colonoscopy or flexible sigmoidoscopy, or once every 24 months for people who are considered high risk.24
You pay coinsurance — 20% of the Medicare-approved amount — for the doctor’s services, plus a copayment if the test is conducted in a hospital. As with other colorectal screening methods, the Part B deductible does not apply.
Why Get Tested for Colon Cancer?
Colon cancer is one of the most common forms of cancer, afflicting adults between ages 65 and 74 most often. Early detection has been shown to reduce deaths from colorectal cancer.25 Medicare coverage reflects established evidence that colorectal cancer screening is potentially life-saving.