Colon cancer is the third most common cancer among both men and women in the United States, according to the National Cancer Institute. However, nearly 30% of adults ages 50 – 75 have never been screened for colon cancer. Considering how effective colonoscopies can be in detecting colon cancer early, it’s surprising that over 20 million older adults haven’t ever received this type or any colon cancer screening.
It’s also surprising that so many older adults in the United States haven’t had a colonoscopy performed considering Medicare covers them at 100%. While Medicare doesn’t cover screening colonoscopies annually at 100%, your doctor may be able to request more frequent screenings depending on your risk level for colon cancer. Medicare covers other types of colon cancer screenings as well.
In most cases, you’ll pay nothing for your Medicare-covered colonoscopy. However, there are some cases where there is a possibility of you having some cost-sharing expenses. Also, depending on the type of screening, the part of Medicare that covers it can vary.
What is colon cancer?
Colon cancer, also called colorectal cancer, is a type of cancer located in the lower end of the digestive tract. Abnormal cells multiply at a rapid rate that can eventually form a cancerous tumor. If caught early, colon cancer is generally treatable.
While colon cancer doesn’t discriminate by age, older adults are at a higher risk of developing colon cancer than younger adults. Other risk factors include, but are not limited to:
- History of colorectal polyps or cancer
- History of Crohn’s disease or ulcerative colitis
- Family history of colon cancer
- Being overweight
- Heavy alcohol use
If Medicare and your doctor consider you to be a high risk for developing colon cancer, Medicare will cover your colonoscopy more often. According to the Centers for Medicare and Medicaid Services, you are considered high risk if you have any of the following:
- An immediate family member who has or have had colorectal cancer or an adenomatous polyp
- A family history of adenomatous polyps or hereditary nonpolyposis colorectal cancer
- A personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease (IBD)
Types of screenings for colon cancer
Routine screenings for colon cancer are important because early detection of colon cancer allows for a more successful treatment. According to the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC), Older adults ages 50-75 should get screened regularly. How often you’re screened will depend on the type of screening you get and your doctor’s recommendations.
The four most common colon cancer screenings are colonoscopies, sigmoidoscopies, fecal occult blood tests (FOBT), and multi-target stool DNA tests. Out of these three screenings, a colonoscopy is the least frequent type of screening, recommended every ten years, whereas the fecal occult blood test is recommended every year. Depending on your history, your doctor may recommend one or multiple of these screenings.
Medicare covers these colon cancer screenings as well as others when they are requested by a doctor who accepts Medicare. If your doctor accepts Medicare assignment and you have had a screening within the restricted time frame, then Medicare will generally cover these tests at 100%.
Multi-Target Stool DNA Tests
Medicare covers at-home stool DNA test every three years for Medicare beneficiaries ages 50-85 who show no symptoms of colorectal cancer and are average risk for developing colorectal cancer.
Colorectal cancer symptoms include lower gastrointestinal pain, bloody stool, and a positive guaiac fecal occult blood test. You’re considered average risk for developing colorectal cancer if you don’t have a personal or family history of IBD, adenomatous polyps, or colorectal cancer.
If you meet the requirements and the facility you send your test to accepts Medicare assignment, then Medicare should cover your at-home test at 100%.
Fecal Occult Blood Tests (FOBT)
Medicare covers FOBTs once a year for Medicare beneficiaries over the age of 50 if recommended by your doctor. Medicare covers these annual tests at 100% if your doctor who performs the test accepts Medicare assignment.
Medicare covers flexible sigmoidoscopies every four years for Medicare beneficiaries over the age of 50. However, if you’ve had a colonoscopy recently and aren’t at high risk for colon cancer, then Medicare won’t cover a sigmoidoscopy until ten years after the previous colonoscopy. If your doctor accepts Medicare assignment, Medicare should cover your screening at 100%. However, if you need a biopsy or lesion removal during the same visit, you may be responsible for your Part B coinsurance.
Medicare covers screening colonoscopies every two years for Medicare beneficiaries of any age who are at high risk of developing colon cancer. However, if you aren’t at high risk, Medicare only covers the screening every ten years. If you have had a flexible sigmoidoscopy over four years ago and haven’t had a colonoscopy in the past ten years, then Medicare will cover a screening colonoscopy.
If your doctor accepts Medicare assignment, then Medicare should cover your screening at 100%. However, like sigmoidoscopies, if a biopsy or lesion removal is done during the same visit, you may be responsible for your Part B coinsurance.
What does “accepts Medicare assignment” mean?
Doctors and facilities have the option to accept Medicare with or without accepting Medicare assignment. Therefore, there are three types of doctors, those who accept Medicare and accept Medicare assignment, those who accept Medicare but do NOT accept Medicare assignment, and those who simply don’t accept Medicare at all.
If you see a doctor or go to a facility who accepts Medicare but doesn’t accept Medicare assignment, then you could be responsible for Part B excess charges.
Part B excess charges equal up to 15% of the Medicare-approved rate of service. For example, if Medicare approves your colonoscopy at 100% coverage, but a doctor who doesn’t accept Medicare assignment performs your colonoscopy, you could end up paying 15% of Medicare’s approved rate instead of paying nothing. If Medicare’s approved rate for a colonoscopy is $2,000, you could be left with a $300 bill in this scenario.
However, if you have a comprehensive Medigap plan, such as Plan G, then you wouldn’t have to worry about your Part B coinsurance or Part B excess charges as Medigap Plan G covers both of these costs. Instead, your colonoscopy would be 100% covered regardless of the type of doctor you see.
If you have a Medicare Advantage plan, make sure to see doctors and use facilities that are in-network with your plan for the most cost-effective prices.
Colonoscopy prep kits
If your doctor recommends a colonoscopy, they will likely prescribe you a prep kit in either a liquid or pill form. This prep kit is meant to clear out your digestive tract, so the doctor has an unobstructed field of view during your colonoscopy.
If your doctor prescribes you a colonoscopy prep kit, you will need to have it filled at a pharmacy and billed under your Part D drug plan. Colonoscopy prep kits are not covered under Part B. You can check your Part D drug formulary to see which types of colonoscopy prep kits your plan covers.
For example, Suprep, a liquid solution bowel prep kit often used for colonoscopies, may be covered under your Part D plan. Prep kits, like Suprep, will likely be subject to your Part D plan’s deductible. So, if you haven’t met your deductible for the year, you could pay the full price for your prep kit.
The price of the kit ultimately depends on your plan and the brand of kit, but for example purposes, Suprep may cost around $100 before your deductible. If you’ve met your deductible, you would instead only pay your Part D coinsurance for whichever tier the prep kit falls under.
Our Client Service Team manager tells us that most of the out-of-pocket expenses that surprise people when it comes to their colonoscopies are related to the prepkit.
It might seem silly for a drug prescribed for a preventative Part B service not to be covered by Part B 100% but it’s not. The reason for this is you are filling the prescription at the pharmacy and giving it to yourself at home. Remember Part D plans cover drugs you administer to yourself whereas Part B drugs are giving to you by a physician or in a facility. Which means if you have a colonoscopy and are put to sleep, that will be covered by Part B.
Get our team on your side
Due to the various rules and requirements for each covered colon cancer screening, billing for a colonoscopy can get tricky. Medicare beneficiaries who have their Medicare plans through Boomer Benefits have our Client Service Team on their side.
Lately, we’ve had some clients call in because Part B didn’t cover their colonoscopy prep kit, and our team has had to explain to them that this falls under Part D. We’ve also had callers with Plan N who called because Medicare didn’t cover their colonoscopy at 100% like they expected it would, and it turned out they had used providers that don’t accept assignment. This results in the kind of costs we described above.
Our client service team will work diligently through your claims and bills to figure out which costs you own, and which need to be re-submitted to Medicare. If you are a client of Boomer Benefits and have a questionable bill, don’t hesitate to reach out for our assistance.