Insurance Coverage for Colorectal Cancer Screening

The American Cancer Society (ACS) believes that all people should have access to cancer screenings, without regard to health insurance coverage.

People should have the option of screening

Limitations on coverage should not keep someone from the benefits of early detection of cancer. ACS supports policies that give all people access to and coverage of early detection tests for cancer. Such policies should be age- and risk-appropriate and based on current scientific evidence as outlined in the American Cancer Society Guideline for Colorectal Cancer Screening. 

Federal law

The Affordable Care Act (ACA) requires both private insurers and Medicare to cover the costs of colorectal cancer screening tests, because these tests are recommended by the United States Preventive Services Task Force (USPSTF). The law stipulates that there should be no out-of-pocket costs for patients, such as co-pays or deductibles, for these screening tests. But the definition of a “screening” test can sometimes be confusing, as discussed below.

The USPSTF currently recommends that people at average risk should start colorectal cancer screening at age 45.

Private health insurance coverage for colorectal cancer screening

The Affordable Care Act requires health plans that started on or after September 23, 2010, to cover colorectal cancer screening tests, which includes a range of test options. In most cases there should be no out-of-pocket costs (such as co-pays or deductibles) for these tests.

For people who choose to be screened with colonoscopy

Many people choose to be screened with colonoscopy. While it might not be right for everyone, it can have some advantages, such as only needing to be done once every 10 years. And if the doctor sees something abnormal during the colonoscopy, it can be biopsied or removed at that time, most likely without needing any other test.

Although many private insurance plans cover the costs of colonoscopy as a screening test, you still might be charged for some services. Review your health insurance plan for specific details, including if your doctor is on your insurance company’s list of “in-network” providers. If the doctor is not in the plan’s network, you may have to pay more out-of-pocket. Call your insurer if you have a question or aren't sure about something.

Soon after the ACA became law, some insurance companies considered a colonoscopy to no longer be just a “screening” test if a polyp was removed during the procedure. It would then be a “diagnostic” test, and would therefore be subject to co-pays and deductibles. However, the US Department of Health and Human Services has clarified that removal of a polyp is an integral part of a screening colonoscopy, and therefore patients with private insurance should not have to pay out-of-pocket for it (although this does not apply to Medicare, as discussed below).

Before you get a screening colonoscopy, ask your insurance company how much (if anything) you should expect to pay for it. Find out if this amount could change based on what’s found during the test. This can help you avoid surprise costs. If you do have large bills afterward, you may be able to appeal the insurance company’s decision.

For people who choose to be screened with a different test

Test options other than colonoscopy are also available, and people might choose one of these other tests for a variety of reasons. Again, the screening test itself should be covered, with no out-of-pocket costs such as co-pays or deductibles. But if you have a screening test other than colonoscopy and the result is positive (abnormal), you will need to have a colonoscopy. Some insurers consider this to be a diagnostic (not screening) colonoscopy, so you may have to pay the usual deductible and co-pay.

Before you get a screening test, check with your insurance provider about what it might mean if you need a colonoscopy as a result of the test, and how much (if anything) you should expect to pay for it. This can help you avoid surprise costs. If you do have large bills afterward, you may be able to appeal the insurance company’s decision.

Medicare coverage for colorectal cancer screening

Medicare covers an initial preventive physical exam for all new Medicare beneficiaries. It must be done within one year of enrolling in Medicare. The “Welcome to Medicare” physical includes referrals for preventive services already covered under Medicare, including colorectal cancer screening tests.

If you’ve had Medicare Part B for longer than 12 months, a yearly “wellness” visit is covered without any cost. This visit is used to develop or update a personalized prevention plan to prevent disease and disability. Your health care provider should discuss a screening schedule (like a checklist) with you for preventive services you should have, including colorectal cancer screening.

What colorectal cancer screening tests does Medicare cover?

Medicare covers the following tests, generally starting at age 45:

Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) once every 12 months.

Stool DNA test (Cologuard) every 3 years for people ages 45 to 85 who do not have symptoms of colorectal cancer and who do not have an increased risk of colorectal cancer.

Flexible sigmoidoscopy every 4 years, but not within 10 years of a previous colonoscopy.

Colonoscopy

• Once every 2 years for those at high risk (regardless of age)
• Once every 10 years for those who are at average risk
• Four years after a flexible sigmoidoscopy for those who are at average risk

Double-contrast barium enema if a doctor determines that its screening value is equal to or better than flexible sigmoidoscopy or colonoscopy:

• Once every 2 years for those who are at high risk
• Once every 4 years for those who are at average risk

At this time, Medicare does not cover the cost of virtual colonoscopy (CT colonography).

If you have questions about your costs, including deductibles or co-pays, it’s best to speak with your insurer.

What would someone on Medicare expect to pay for a colorectal cancer screening test?

• FOBT/FIT: Covered at no cost for those age 45 or older* (no co-insurance or Part B deductible)
• Stool DNA test (Cologuard): Covered at no cost* for those age 45 to 85 as long as they are not at increased risk of colorectal cancer and don’t have symptoms of colorectal cancer (no co-insurance or Part B deductible)

It's important to know that if you have a positive result on a screening FOBT, FIT, or stool DNA lab test, Medicare will cover the cost of a follow-on screening colonoscopy. You will not have to pay for this test as long as your doctor or other qualified health care provider accepts assignment. However, if a polyp or other tissue is found and removed during the follow-up screening colonoscopy, you may have to pay 15% of the Medicare-approved amount for your doctor’s services.

• Colonoscopy: Covered at no cost* at any age (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. Note: If the test results in a biopsy or removal of a growth, it’s no longer a “screening” test, and you will be charged the 15% co-insurance and/or a co-pay (but you don’t have to pay the deductible).
• Flexible sigmoidoscopy: Covered at no cost* (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. Note: If the test results in a biopsy or removal of a growth, it’s no longer a “screening” test, and you will be charged the 15% co-insurance and/or a co-pay (but you don't have to pay the Part B deductible).
• Double-contrast barium enema: You pay 20% of the Medicare-approved amount for the doctor services. If the test is done in an outpatient hospital department or ambulatory surgical center, you also pay the hospital co-payment (but you don’t have to pay the Part B deductible).

If you’re getting a screening colonoscopy (or flexible sigmoidoscopy), be sure to find whether you might have to pay for any related charges. This can help you avoid surprise costs.

• Ask how much you will have to pay if a polyp is removed or a biopsy is done. You may have a co-pay 15% of the Medicare-approved amount for the doctor’s services.
• You may also have to pay for the bowel prep kit unless your Medicare Part D or Medicare Advantage plan covers the cost.
• Depending on where your colonoscopy is done, you may have to pay 15% co-insurance for a facility fee.

*This service is covered at no cost as long as the doctor accepts assignment (the amount Medicare pays as the full payment). Doctors that do not accept assignment are required to tell you up front.

Medicaid coverage for colorectal cancer screening

States are authorized to cover colorectal screening under their Medicaid programs. But unlike Medicare, there’s no federal assurance that all state Medicaid programs must cover colorectal cancer screening in people without symptoms. Medicaid coverage for colorectal cancer screening varies by state. Some states cover fecal occult blood testing (FOBT), while others cover colorectal cancer screening if a doctor determines the test is medically necessary. In some states, coverage varies according to which Medicaid managed care plan a person is enrolled in.