How Much Does Medicare Pay for a Colonoscopy?

Colonoscopies are an important tool for maintaining digestive health and detecting colorectal cancer early. Many individuals rely on Medicare for their healthcare coverage, and understanding how these procedures are covered can help manage potential costs. Medicare covers colonoscopies, but the extent of coverage and out-of-pocket expenses vary based on the procedure’s purpose and Medicare plan.

Medicare Coverage for Colonoscopies

Medicare categorizes colonoscopies into two main types: screening and diagnostic. A screening colonoscopy is a preventive service performed when an individual has no symptoms, aiming to detect potential issues like polyps. Diagnostic colonoscopies are conducted to investigate specific symptoms, follow up on abnormal test results, or remove polyps found during a screening. This distinction significantly impacts coverage.

Medicare Part B covers screening colonoscopies. For individuals at average risk, Medicare covers a screening colonoscopy once every 120 months (10 years). If a person has had a flexible sigmoidoscopy, a screening colonoscopy is covered 48 months later. For those at high risk, such as individuals with a family history of the disease or a personal history of polyps or inflammatory bowel disease, Medicare covers a screening colonoscopy once every 24 months (two years).

Medicare Part B also covers diagnostic colonoscopies when medically necessary. This includes situations where a screening colonoscopy identifies and leads to the removal of polyps or other tissue. If polyps are found and removed, the procedure’s classification can change from screening to diagnostic, affecting financial responsibility. Ensure the provider accepts Medicare assignment, meaning they accept Medicare’s approved payment as full payment.

Understanding Your Costs Under Original Medicare

Under Original Medicare (Part A and Part B), colonoscopy costs depend on whether the procedure is for screening or diagnostic purposes. For a screening colonoscopy, Medicare Part B generally covers 100% of the Medicare-approved amount, meaning beneficiaries typically pay nothing out-of-pocket if the doctor accepts assignment. The Part B deductible does not apply to these preventive screenings.

If a screening colonoscopy leads to the discovery and removal of polyps or other tissue, the procedure’s classification changes to diagnostic, and some costs may apply. For the removal of polyps or other diagnostic services performed during a screening colonoscopy, beneficiaries are responsible for 15% coinsurance of the Medicare-approved amount for the doctor’s services. This 15% coinsurance rate applies from 2023 through 2026. A 15% coinsurance may also apply for facility fees if the procedure is performed in a hospital outpatient setting or ambulatory surgical center.

For colonoscopies that are diagnostic from the outset, performed due to existing symptoms or to follow up on a positive non-invasive test, standard Part B deductible and coinsurance rules apply. The Medicare Part B annual deductible for 2025 is $257. After this deductible is met, beneficiaries typically pay 20% coinsurance of the Medicare-approved amount for the procedure. While most colonoscopies are outpatient, if an inpatient hospital stay becomes medically necessary, Medicare Part A costs, such as the Part A deductible, could apply.

How Medicare Advantage and Medigap Affect Payments

Medicare Advantage Plans (Medicare Part C) are offered by private companies approved by Medicare and must cover at least all services Original Medicare covers. This means Medicare Advantage plans cover preventive screening colonoscopies at no cost. However, for diagnostic colonoscopies or when a screening colonoscopy becomes diagnostic (e.g., due to polyp removal), out-of-pocket costs like copayments or coinsurance vary by plan structure and network. Beneficiaries should review their plan’s Evidence of Coverage or contact their plan directly to understand financial responsibilities.

Medigap policies (Medicare Supplement Insurance) help pay for some out-of-pocket costs associated with Original Medicare. These plans cover costs like deductibles, coinsurance, and copayments that Original Medicare does not cover. For diagnostic colonoscopies, or the diagnostic portion of a screening colonoscopy where polyps are removed, a Medigap policy can significantly reduce a beneficiary’s financial liability. Depending on the specific Medigap plan, these policies can cover the Part B deductible and/or the 15% or 20% coinsurance. For example, a comprehensive Medigap plan may cover the Part B coinsurance, potentially resulting in no out-of-pocket costs.