Colorectal cancer remains the fourth most common type of cancer in the U.S. With that said, is there ever an instance where you can get a free colonoscopy?

With 9 out of 10 colorectal cancer diagnoses impacting people over the age of forty, colonoscopy screenings are often prescribed by physicians to patients in that age category. In fact, federal health care law mandates that specific vital preventive services, including colonoscopies, be provided to patients at no out-of-pocket cost.

However, insurance coverage of colonoscopy screening for colorectal cancer has caused considerable hand-wringing and annoyance for patients; surprise bills and blurry copay and deductible policies seem to be the norm, and clarity and transparency about the process have been hard to come by.

Below we’ll set the record straight about when your colonoscopy is free, issues surrounding Medicare premiums and potential delays in establishing Medicaid eligibility.

Federal Law

The Affordable Care Act (ACA) mandates that health plans include coverage of colorectal cancer screening. The ACA significantly increased the scope of preventive medical services to individuals between 50 and 75-years old, obligating commercial insurance providers to include colonoscopy screenings to detect colorectal cancer free of charge and without any out-of-pocket expenses.

The ACA specifies that insurers must fully cover services that are highly rated by the U.S. Preventive Services Task Force (USPSTF) such as colonoscopy (which earned an A rating for adults over 50). However, the ACA protections do not apply to all insurance plans. To determine the status of your plan, you should contact your insurance company or your human resources manager.

Private Health Insurance Coverage

According to the American Cancer Society, many private insurance programs will cover colonoscopy, but you could incur other fees depending on the reason for your screening. Colonoscopies performed to assess particular problems such as abdominal pain, intestinal bleeding, or decreased red blood cell count are typically deemed diagnostic instead of screening procedures. In that case, you may be on the hook for deductible and copay charges.

If your doctor finds a polyp (or other growth) during your colonoscopy requiring removal or a biopsy, your insurance plan may also deem the procedure diagnostic. It is essential to review all the elements of your insurance program, especially if your doctor is in your plan’s network. If not, your out-of-pocket expenses could increase.

The best course of action to avoid surprise fees is to call your insurance company before scheduling your colonoscopy. Ask them how much you should expect to pay for it and under what circumstances the amount could change based on what’s found during the test. If you do get hit with a hefty bill after your screening, you may be able to appeal your insurer’s decision.

Another grey area involving private insurance coverage is with subsequent screenings after polyps have been found or removed. Once a doctor needs to take action, many insurance programs change the classification of future colonoscopy testing from preventive to diagnostic. And higher risk colorectal cancer testing isn’t specified on the USPSTF recommendation list. Therefore, insurance providers are not obligated to cover it free from copayments or deductibles, meaning they may require you to cost-share for the cost of the colonoscopy and the doctor’s fee.

For example, say upon your initial colonoscopy screening your doctor found and removed a polyp, and then asked you to return for a follow-up test in three years. Your next colonoscopy may be deemed as diagnostic, leaving you to foot a portion of the bill and potentially to advance a sizable sum for the deductible.

The question many patients pose is: shouldn’t the law protect people in those types of situations from being charged for more frequent but necessary screening?

Medicare Colonoscopy Coverage

Digestive Disease ConsultantsMedicare will cover colonoscopy tests free of charge or any out-of-pocket expenses. Included in the coverage are screenings every ten years, and every two years if you are deemed high-risk. The catch here, as opposed to private insurance, is that if a growth is detected during your initial screening, the test is classified as diagnostic and you may get hit with a copayment charge.

The American Cancer Society confirms that for new enrollees, Medicare will cover “a preventive physical exam” within a year of registering. The “Welcome to Medicare” exam can include referrals for other screening tests already covered under Medicare, including colonoscopy.

For patients holding Medicare Part B for over a year, an annual “wellness” visit is covered free of charge. The goal of the visit to establish an individualized disease prevention program.

You should consult your provider to develop a preventive screening schedule that would include a colonoscopy.

Medicare covers colonoscopy under the following circumstances:

  • One time every two years for high-risk patients of any age
  • Once every ten years for people at average risk
  • Four years after a flexible sigmoidoscopy for patients at average risk

However, as with private insurance, a caveat exists. The American Cancer Society reports that “Medicare will cover a colonoscopy free of charge when the test is performed for screening purposes. If a polyp is found and needs to be removed or a biopsy is done, the test is not considered a “screening,” and patients will be charged the 20% co-insurance and a co-pay.”

Medicaid Coverage

States have the authority to cover colonoscopy screening under Medicaid, however, in the case of individuals with no symptoms, state Medicaid programs are not obligated by the federal government to provide colorectal cancer screening.

Medicaid coverage for colonoscopy is done on a state-by-state basis with some states including fecal occult blood testing (FOBT), and others providing colonoscopy tests if a physician has determined them medical necessities.

If you need any more information, please feel free to contact us. We’ll be happy to answer your questions or address any of your concerns.