Does Medicare Cover Cologuard

As we age, we have to start screening ourselves more often to attempt to catch health concerns early on. Colonoscopies are one way that we check for colon cancers. Now there are additional methods for screening for colorectal cancer, such as Cologuard, which is growing in popularity because the process is considerably less invasive than a colonoscopy.

The American Cancer Society estimates over 100,000 new colon cancer cases this year. Moreover, colon cancer is the 3rd most common cancer in the United States. Fortunately, colon cancer has more than a 90% survival rate if early detection occurs.

While Medicare covers Cologuard, it isn’t your only option for colorectal cancer screenings. You can also have a Barium Enema, Colonoscopy, or fecal occult blood test.

What is Cologuard?

Cologuard is the only Food and Drug Administration (FDA)-approved at-home test or detection tool used to test fecal matter to help determine if colorectal cancer is present. Cologuard is a simple, non-invasive procedure.

Once you collect the sample and send it off, it’s evaluated in a lab to see if there are any abnormal DNA mutations or traces of blood in the stool. It can also see if there are specific genetic markers available to help determine if there are polyps in the digestive tract.

How does Cologuard work?

Colorguard analyzes your DNA for unusual structures and blood in stool that precancerous growths could cause to detect colorectal cancer. To receive a Cologuard test, you’ll need a prescription from your healthcare provider. Then, you need to print out a form on the Cologuard website and get to your doctor before he can issue the prescription.

YourCologuard kit will arrive in the mail and contains all the items needed to collect a stool sample. The kit will include a bracket, collection bucket, probe, lab tube set, and a preservative solution to preserve the specimen for shipping. Your kit will include a prepaid shipping label for sending the sample back to the lab.

Are Cologuard tests covered by Medicare?

Medicare covers Cologuard tests every three years under Medicare Part B as a preventive service in most cases. You must meet the following eligibility requirements for the test to be covered.

• You must not be showing any signs or symptoms of colorectal disease.
• You must be between 50-85 years old.
• You must not have any personal history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease.
• You must not have any family history of risk factors such as hereditary adenomatous polyps, nonpolyposis colorectal cancer, or familial adenomatous polyposis.

Most insurance must follow the rules outlined by the U.S. Preventive Services Task Force (USPSTF). They set the rules for insurance companies involved with the Affordable Care Act. The Medicare program isn’t required to follow these requirements because the Centers for Medicare & Medicaid Services dictate the requirements for Medicare.

How much does a Cologuard test cost on Medicare?

A Cologuard test can cost anywhere from $400 to $600. Your cost will depend on your insurance. For instance, most individuals on Medicare should have a $0 coinsurance for the test if they meet the requirements.

If the test is considered preventive, Medicare should cover the costs of colon cancer screenings using a colonoscopy or Cologuard. Sometimes, during a colonoscopy procedure, a problem is encountered. If a polyp is found and treated, you can expect it to no longer be preventive. As a result, the beneficiary would be responsible for the Medicare cost share in this case. They would be subject to the Medicare Part B deductible and coinsurance.

The Cologuard test combines two fecal immunochemical tests. One is used to look for blood in the stool, and the other to search for DNA indicating abnormal cancer cells. Then the test results are used in the detection of colorectal cancer. Suppose you enroll in a Medicare Supplement insurance coverage or Medicare Advantage plan. In that case, your costs for diagnostic screenings could be different.

Medicare Supplement Cost for Cologuard and Colonoscopy

Medicare Supplement plans are secondary to Original Medicare. A Medigap plan covers anything covered by Medicare Part A or Medicare Part B. Since these Medigap options fill in the gaps of your required cost share, preventive colorectal cancer screenings will have no cost. Your Medicare Supplement plan could cover most related expenses if the diagnostic test becomes diagnostic.

Medicare Advantage Costs for Cologuard and Colonoscopy

Medicare Part C plans follow the rules outlined by the Centers for Medicare and Medicaid Services. These private insurance companies that administer these plans have to abide by these guidelines. If the procedure or colorectal cancer screening test falls under the preventive screening rules, the Medicare beneficiary wouldn’t be responsible for payment.

However, like the example above, if the procedure is considered diagnostic, you’ll have to pay your plan’s scheduled copay for the procedure. Your summary of benefits outlines the cost of procedures.

Pros and Cons of Cologuard vs. Colonoscopy

Like everything, there are pros and cons to any test or procedure. Next, we’ll list the benefits and fallbacks of both colonoscopies and Cologuard.

Cologuard Pros

• Covered by Medicare
• Convenient
• No bowel prep
• Non-invasive

Cologuard Cons

• 13% false positive rate that increases as you age
• Required every three years
• Misses 8% of colorectal cancer
• Misses 60% of advanced polyps
• If you’re showing symptoms of colorectal cancer, Cologuard can’t isn’t an option.

Colonoscopy Pros

• A complete test to prevent colorectal cancer and deaths related to colorectal cancer
• Covered by Medicare
• Needed every ten years
• Colonoscopy is the only approved test for patients that have symptoms.
• The most trusted test for detection of cancerous and precancerous polyps and lesions

Colonoscopy Cons

• Risk of complications (minor)
• Bowel prep required
• Invasive procedure
• Sedation a requirement
• Dependant on someone performing the procedure

FAQs

How often can you get a Cologuard test with Medicare?

Medicare will cover the full coast

Will Medicare pay for a colonoscopy after a Cologuard test?

Suppose you require a colonoscopy after receiving results from a Cologuard test. In that case, Medicare will likely bill you for a diagnostic colonoscopy. Medicare covers a preventive colonoscopy every 24 months if you’re at high risk for colorectal cancer.

Suppose your colonoscopy is after a test indicates you may have signs of cancer. In that case, a diagnostic test may be necessary. In this case, since it’s diagnostic, you’ll be responsible for the Medicare out-of-pocket costs. The cost share can include deductibles, copayments, or coinsurance.

What are the Medicare guidelines to cover Cologuard?

Medicare covers one Cologuard test every three years. To meet the requirements, you must be between 50 and 85, asymptomatic, and at average risk of colorectal cancer.

What is the difference between Cologuard and a colonoscopy?

Cologuard is a non-invasive stool DNA test that sends a stool sample to a lab for evaluation. A colonoscopy is an outpatient procedure in which your doctor will look at the inside of the gastrointestinal system. It looks specifically at your colon and rectum using a colonoscope. A colonoscope is a finger-width long flexible tube with a light and a camera tube on the end.

What is the cost of a Cologuard test?

Without insurance, a Cologuard test will range from $400-$600. Your health insurance will determine the actual cost of the test. Additionally, Medicare will cover preventive screening colonoscopies at no cost.

Who should have a Cologuard test?

Individuals between 50 and 86 with average risk and no symptoms should have a Cologuard test to screen for colorectal cancer. Every three years, a Cologuard test should occur.

Is Cologuard covered under Medicare Part D?

Medicare Part D doesn’t cover Cologuard. Part D coverage helps pay for prescription drugs picked up from the pharmacy. Medicare Part B covers Cologuard as a preventive outpatient medical service.

What’s a Sigmoidoscopy?

Sigmoidoscopy is a medical examination of the large intestine. Its administered from the rectum to the nearest section of the colon. It’s a minimally invasive procedure.

There are two different types of sigmoidoscopy.

• Flexible Sigmoidoscopy
  • This style uses a flexible endoscope.
• Rigid Sigmoidoscopy
  • This style uses a rigid device.

Who can take the Cologuard test?

If you meet the below requirements, you’re eligible for a Cologuard test.

• You must be between 50-85 years old.
• You must not be showing any signs or symptoms of colorectal disease.
• You must not have any personal history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease.
  • You can’t have a family history of any of the following:
    • hereditary adenomatous polyps
    • nonpolyposis colorectal cancer
    • colorectal cancers
    • familial adenomatous polyposis.

Getting Coverage for Colorectal Cancer Screenings

When it comes to maintaining your healthcare, preventive screenings are super important. While this isn’t an exact science, it helps to catch potential health issues early on. If a screening shows concern, it’s equally important to have the proper healthcare to help cover treatment costs.

Our licensed insurance agents can assist in educating you on the options available and help you find the ones that fit your needs. For help, call us at the number listed at the top of the page, or fill out our online request form.

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