March 16, 2022 Health & Wellness
Colorectal Cancer Screenings for Medicare Beneficiaries
Our recent blog answered the question, “Does Medicare cover glaucoma tests?” Since March is also Colorectal Cancer Awareness Month, we decided we’d talk about what preventive and screening services related to colorectal cancer are covered by Medicare next.
There are five different types of screenings for colorectal cancer, including multi-target stool DNA tests, barium enemas, colonoscopies, fecal occult blood tests, and flexible sigmoidoscopies. Medicare’s coverage for these procedures will vary depending on your age and risk factors. We’ll cover some of the specific qualifications below, but you’ll always want to be sure to check with your health care provider and health insurance Plan prior to scheduling any procedures.
Multi-target Stool DNA Tests
Medicare covers a multi-target stool DNA lab test (done at home) once every three years for beneficiaries at average risk for developing colorectal cancer who meet all the following criteria:
- You are 50-85 years old.
- You do not have symptoms of colorectal disease (including, but not limited to, lower gastrointestinal pain, blood in your stool, a positive guaiac fecal occult blood test, or a positive fecal immunochemical test).
- You do not have a personal history of adenomatous polyps, colorectal cancer, inflammatory bowel disease, Chron’s Disease, or ulcerative colitis.
- You do not have a family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or heredity nonpolyposis colorectal cancer.
If you’re on Original Medicare and your health care provider accepts assignment, you will not have to pay anything for this test. Assignment is when the provider agrees to be paid directly by Medicare for the amount Medicare approves for the service, and to not bill you for anything more than Medicare deductibles and coinsurance.
Medicare Part B will cover a barium enema test if you’re at least 50 years old. The test is covered once every 24 months if you’re at high risk for colorectal cancer, or once every 48 months if it’s used instead of a colonoscopy or flexible sigmoidoscopy.
If you’re on Original Medicare, you’ll pay 20% of the Medicare-Approved Amount for the test. The Part B deductible doesn’t apply to this test, but if you receive the service in an outpatient hospital setting, you’ll also need to pay a copayment.
Medicare covers colonoscopies once every 24 months for beneficiaries at risk of developing colorectal cancer. Medicare will cover a colonoscopy either once every 120 months or 48 months after a previous flexible sigmoidoscopy if you are not at high risk for colorectal cancer. This test does not have a minimum age requirement for coverage.
If you’re on Original Medicare and your qualified health care provider accepts assignment, you won’t pay anything for a colonoscopy. However, you may have to pay 20% of the Medicare-Approved Amount if a tissue or polyp is found and removed during the procedure. You’ll also pay a copayment if the procedure takes place in a hospital, but then the Part B deductible does not apply.
Fecal Occult Blood Tests
If you are 50 years old or older and receive a referral from a qualified health care provider (such as a doctor, physician assistant, nurse practitioner, or clinical nurse specialist), Medicare will cover fecal occult blood tests once every 12 months. If you’re on Original Medicare and your health care provider accepts assignment, you will not have to pay anything for this screening.
For most patients aged 50 and older, Medicare will cover a flexible sigmoidoscopy screening once every 48 months. If you’re not at high risk for colorectal cancer, Medicare will cover this test 120 months after your previous colonoscopy screening.
If you’re on Original Medicare and your qualified health care provider accepts assignment, you will not have to pay for this procedure. However, costs may apply if a lesion or growth is removed or biopsied because Medicare would then consider the procedure diagnostic. In this instance, the Part B deductible does not apply, but you may have to pay coinsurance and/or a copayment.
Notes About Your Costs
The specific amount you’ll have to pay for these procedures can depend on things like how much your doctor charges, where you get the test done, if your doctor accepts assignment, and if you have other insurance, so please make sure to talk to your health care provider prior to scheduling anything.
As a reminder, the Medicare-Approved Amount is sometimes less than the amount the doctor charges, so you would be responsible to pay the difference if that is the case. Additionally, the health care provider may recommend you get tested more often than Medicare provides coverage for or that you use services Medicare doesn’t cover. You might have to pay for some or all the costs in those instances, so be sure you understand exactly what is going to be expected prior to receiving any services.
Never be afraid to ask questions before receiving any services, including asking what specifically is being recommended for you, why it is being recommended, and what the cost will be (or if Medicare will cover any of it for you).
What to Do if Your Bills Look Incorrect
If you receive your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) and something looks wrong, you should first contact your health care provider for clarification.
However, if you believe you’ve been billed fraudulently for a service, Senior Medicare Patrol is here to help! To report suspected health care fraud, you can reach Wisconsin SMP via email at firstname.lastname@example.org or by calling our toll-free and confidential helpline at 888-818-2611.