Does Medicare Cover Colonoscopies? What You Need to Know

A colonoscopy is a medical procedure that uses a flexible tube with a camera to view the inside of the large intestine and rectum, detecting abnormalities like polyps or signs of cancer. Medicare provides coverage for colonoscopies, recognizing their role in maintaining health and detecting potential issues early.

Understanding Medicare Coverage

Medicare covers colonoscopies, with specific coverage depending on whether the procedure is considered a “screening” or a “diagnostic.” A screening colonoscopy is a preventive measure performed when an individual has no symptoms, aiming to detect colorectal cancer early. Conversely, a diagnostic colonoscopy is performed when a person exhibits symptoms, has abnormal test results, or requires follow-up from a previous procedure. The distinction between screening and diagnostic procedures significantly impacts how costs are covered.

Medicare Part B covers screening colonoscopies as a preventive service, including the procedure itself and associated professional services. For diagnostic colonoscopies, Medicare Part B also provides coverage for outpatient procedures. If a diagnostic colonoscopy requires an inpatient hospital stay, Medicare Part A may cover those costs.

Covered Frequencies and Costs

Medicare covers screening colonoscopies at specific intervals. For individuals considered at average risk for colorectal cancer, Medicare covers a screening colonoscopy once every 10 years, or every 48 months following a flexible sigmoidoscopy. If you are at high risk for colorectal cancer, Medicare covers a screening colonoscopy more frequently, typically once every 24 months. High risk factors include a personal history of polyps or colorectal cancer, a family history of these conditions, or a personal history of inflammatory bowel disease.

For screening colonoscopies, if your healthcare provider accepts Medicare assignment, you generally pay nothing for the test. This means there is no deductible or coinsurance applied to the screening procedure itself. However, if a screening colonoscopy becomes diagnostic—for example, if a polyp is found and removed—the procedure may be reclassified. In such cases, the Medicare Part B deductible and a percentage of the Medicare-approved amount, typically 20% coinsurance, may apply to the diagnostic portion of the service. This coinsurance rate for diagnostic procedures that begin as screenings is subject to a phased reduction, being 15% from 2023 to 2026, decreasing to 10% from 2027 to 2029, and will be waived starting in 2030.

Important Considerations

Before your colonoscopy, it is important to confirm that your healthcare provider and the facility accept Medicare assignment. This ensures that they agree to be paid directly by Medicare and will not bill you for more than the Medicare deductible and coinsurance amounts. Understanding this can prevent unexpected out-of-pocket expenses.

If a screening colonoscopy turns into a diagnostic procedure (e.g., if a polyp is found and removed), this change can impact your out-of-pocket costs, as the diagnostic portion may incur coinsurance. It is advisable to discuss this possibility with your doctor beforehand to understand the potential financial implications.