How Much Does a Colonoscopy Cost With Medicare?

Colonoscopies are a recommended procedure for screening and preventing colorectal cancer. This examination uses a flexible, camera-equipped scope to visualize the large intestine, allowing for the detection and removal of polyps. Understanding Medicare coverage is important for beneficiaries to anticipate costs.

Medicare’s Colonoscopy Coverage

Medicare Part B covers colonoscopies, categorizing them as either screening (preventive) or diagnostic procedures. Screening colonoscopies detect colorectal cancer without specific symptoms, while diagnostic colonoscopies are conducted due to symptoms, an abnormal screening result, or for follow-up.

For individuals at average risk, Medicare Part B covers a screening colonoscopy once every 120 months (10 years). If a flexible sigmoidoscopy was performed previously, a screening colonoscopy is covered 48 months later. For those at a higher risk, Medicare covers a screening colonoscopy once every 24 months. High risk factors include a personal history of certain polyps or colorectal cancer, or a family history of the disease.

Medicare covers screening colonoscopies at 100% of the Medicare-approved amount, meaning beneficiaries pay nothing if the healthcare provider accepts assignment. This applies even if the Part B deductible has not been met. Diagnostic colonoscopies, however, are subject to different cost-sharing rules.

Your Potential Out-of-Pocket Expenses

While screening colonoscopies are generally fully covered by Medicare Part B, certain situations can lead to out-of-pocket costs. The most common scenario involves a screening colonoscopy that becomes diagnostic. If a polyp or other tissue is found and removed during a procedure initially intended as a screening, the procedure’s classification changes to diagnostic.

In such cases, beneficiaries become responsible for coinsurance. For the physician’s services, a 15% coinsurance of the Medicare-approved amount applies. If the procedure is performed in an outpatient setting, such as a hospital outpatient department or ambulatory surgical center, an additional 15% facility coinsurance may also apply. The Part B deductible does not apply in this specific scenario where a screening turns diagnostic.

Beyond the procedure itself, beneficiaries may also incur costs for colonoscopy preparation medications. While the Centers for Medicare & Medicaid Services (CMS) clarified that bowel prep kits for screening colonoscopies should be covered, many Medicare beneficiaries still face these expenses. Median out-of-pocket costs for prep kits can range from approximately $8 for high-volume preparations to about $55.99 for low-volume preparations.

How Other Medicare Plans Affect Costs

Beneficiaries enrolled in Medicare Advantage (Part C) plans or those with Medigap (Medicare Supplement Insurance) policies will experience different out-of-pocket costs for colonoscopies compared to Original Medicare. Medicare Advantage plans are required to cover at least the same benefits as Original Medicare, including colonoscopies. However, these plans may have different cost-sharing structures, such as copayments or coinsurance, and often operate within specific provider networks. Beneficiaries with Medicare Advantage plans should contact their plan directly to understand their specific cost-sharing and network requirements.

Medigap policies help cover the out-of-pocket expenses that Original Medicare does not, such as the Part B deductible and coinsurance. If a diagnostic colonoscopy is performed, or if a screening colonoscopy turns diagnostic, Medigap plans can significantly reduce or eliminate the coinsurance and deductible responsibilities that would otherwise fall to the beneficiary under Original Medicare. The extent of coverage depends on the specific Medigap plan letter chosen.