Does medicare pay for colonoscopy after age 75

A. The answer is likely yes, unless your doctor thinks you should continue for some reason. The U.S. Preventive Services Task Force (USPSTF) recommends routine colorectal cancer screening, such as colonoscopy, for everyone from age 45 to 75. Some people may be advised to start screening earlier if they have a family history of colon cancer, if certain genetic conditions run in their family, or if they have an inflammatory bowel disease, such as Crohn’s disease. The USPSTF says that most people can stop screening at age 75, but people should ask their doctor if they might need to continue screening between ages 76 and 85. Some people may benefit from screening beyond that age based on their individual risk factors and overall health.

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Medicare pays for colonoscopy screening tests, but how often they're covered depends on whether you are at high or low risk for colorectal cancer. If you are at low risk for colorectal cancer, Medicare covers the full cost of a colonoscopy every 10 years. High-risk patients can get a free test every two years.

If you're not considered high risk but develop health concerns related to colorectal cancer, you'll need a diagnostic test. Medicare pays 80% for a diagnostic colonoscopy, and you pay 20%.

Medicare Advantage plans save you money on diagnostic colonoscopies compared to Original Medicare. When searching for health insurance, we suggest Medicare Advantage plans as a first option.

Regular colonoscopies are important for maintaining good health. Colon cancer is one of the most common and deadly cancers but is treatable if caught early.

• Does Medicare cover colonoscopy?
• Coverage for screening and diagnostic colonoscopies
• Other tests to screen for colon cancer
• How do Medigap plans cover colonoscopies?
• Does Medicare Advantage cover colonoscopies?

Does Medicare cover colonoscopy procedures?

Medicare covers colonoscopies whether they're done as routine screening tests or to diagnose a potential problem. What you pay out of pocket depends on the reason for your procedure.

Original Medicare covers both screening and diagnostic colonoscopies under Part B (medical) insurance. You get a free screening every 24 months if you’re at high risk for colorectal cancer. If you are not at high risk, Medicare covers your test in full once every 10 years.

If your colonoscopy is done to diagnose a problem, you'll pay 20% of the cost.

Medicare has no minimum or maximum age limit for a screening colonoscopy, and you pay nothing if your health care provider accepts Medicare assignment.

Medicare Advantage plans provide free colonoscopy screenings at the same frequency as Original Medicare. But many Medicare Advantage plans also provide diagnostic colonoscopies and polyp removal free of charge. Under Original Medicare, you pay 20% for those services.

Both Original Medicare and Medicare Advantage plans cover colonoscopies done in an ambulatory surgery centeror a hospital outpatient setting.

Does Medicare cover both screening and diagnostic colonoscopies?

Medicare pays for both screening and diagnostic colonoscopies. The tests are done the same way, with similar equipment, but are covered differently by Medicare.

A screening colonoscopy is a preventive procedure done to make sure the colon is healthy. You're covered for a screening every 10 years if you're at low risk for colorectal cancer, meaning you:

• Had no lower gastrointestinal signs or symptoms before the colonoscopy
• Had no polyps or masses found during the colonoscopy
• Have no family or personal history of polyps or colon cancer

If you're at high risk for developing colorectal cancer, Medicare will cover your screening test every two years. You're considered high risk if you:

• Have a personal history of colorectal cancer, a certain type of polyp or an inflammatory bowel disease such as Crohn’s disease or ulcerative colitis
• Have a close relative — a parent, sibling or child — who had colorectal cancer or a potentially cancerous polyp
• Have a family history of inherited ailments linked to colorectal cancer

Original Medicare covers screening colonoscopies at 100%. You pay no Part B deductible or coinsurance for a screening test.

A diagnostic colonoscopy is a different type of test. It looks for potential problems due to stomach pain that doesn’t improve, anemia or if you've had polyps within the past 10 years.

Original Medicare covers diagnostic colonoscopies at 80%. You won't pay a deductible but will pay the remaining 20% of the procedure cost.

Can a screening colonoscopy become a diagnostic procedure?

Yes. You may go in for a screening colonoscopy and end up needing a diagnostic colonoscopy. If your doctor finds and removes a polyp or other tissue during a screening, your colonoscopy is then considered diagnostic rather than preventive. In that case, you'll be charged 20% of the cost of your doctor’s services.

What is the Medicare colonoscopy loophole?

The "Medicare loophole" happens when your routine colonoscopy screening detects medical issues. When that occurs, your test is no longer considered a screening and is no longer free. It then becomes a diagnostic procedure, and you're charged the 20% Medicare coinsurance.

In 2020, a "Medicare loophole" law was passed that protects Medicare patients who get a screening colonoscopy that turns into a diagnostic procedure.

The law, called the Removing Barriers to Colorectal Cancer Screening Act, gradually reduces Medicare patients' coinsurance and will eliminate out-of-pocket costs completely by 2030. The colonoscopy procedure itself will not change, just how patients are billed.

Meanwhile, if you're billed for a colonoscopy screening, you may want to contact your provider or Medicare (at 800-633-4227 or Medicare.gov) to be sure you are charged the correct amount.

Does Medicare cover other tests for colon cancer?

Medicare covers three alternative methods for colon cancer screening. These tests can be done at home or by providing a blood sample, and they're free if ordered by a doctor or other qualified health care provider.The alternative tests are only for patients who have no signs or symptoms and are at average risk (not high risk) of developing colorectal cancer. Coverage may vary by test type and age group.

Test type

Medicare benefit

Fecal occult blood test (FOBT)

How do Medigap plans cover colonoscopies?

Your Medigap plan pays for colonoscopy costs left over after Medicare pays.

Medicare pays only 80% of the cost for a diagnostic colonoscopy, meaning you pay the remaining 20%. You would submit those charges to your Medigap plan, which would pay all or part of the cost, depending on your policy.

Medicare provides a free screening colonoscopy every 24 months for high-risk patients and every 10 years for people at low risk for colorectal cancer. Since the procedure is covered in full, you have no out-of-pocket costs to file with your Medigap plan.

Does Medicare Advantage cover colonoscopies?

Medicare Advantage plans cover at least the same colonoscopy services as Original Medicare. But along with regular screenings, Medicare Advantage policies provide added coverage for diagnostic colonoscopies, making Medicare Advantage the cheaper option for those services. The added benefits are similar across all plans we reviewed, with one exception.

Best Medicare Advantage options for colonoscopies

We reviewed several Medicare Advantage HMO plans and found similar colonoscopy coverage among all but one insurer. Except for Blue Cross and Blue Shield, Medicare Advantage policies all provide free diagnostic colonoscopies and polyp removals — even when a scheduled screening turns into a diagnostic procedure.

With a Medicare Advantage HMO, you'll need a referral from your family doctor and must use a network specialist. Your doctor also may need to obtain preauthorizationfrom your insurer. As with Original Medicare, your colonoscopy must be done in an ambulatory surgery center or outpatient hospital to be covered.

Company

Colonoscopy benefit

Medicare rating

Frequently asked questions

Does Medicare pay for colonoscopy anesthesia?

Yes. Medicare Part B covers the full cost of anesthesia used during a colonoscopy to screen for or diagnose colon cancer.

What colonoscopy prep does Medicare cover?

If your doctor orders a prescription colonoscopy "prep kit," the medication is covered by a Medicare drug policy, subject to plan benefits. You would pay for anything not covered by a Medicare drug plan, including over-the-counter medications like Miralax or Dulcolax.

Will Medicare pay for a colonoscopy after age 70?

Yes. Medicare pays for a colonoscopy at any age — there is no minimum or maximum age to qualify. But Medicare does limit how often your colonoscopy is covered, depending on the reason for your procedure.

Methodology

Our policy recommendations are based on the plan or plans that provide the best colonoscopy coverage. Although monthly premiums were not a factor, all the Medicare Advantage HMO plans we reviewed charge no monthly premium. Medicare Advantage coverage details were sourced from AARP/UnitedHealthcare, Aetna, Blue Cross Blue Shield, Cigna, Humana and Kaiser Permanente. Information on Original Medicare colonoscopy coverage was obtained from Medicare.gov and CMS.gov.

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Callers to QWIS will be directed to a licensed and certified representative of Medicare Supplement insurance and/or Medicare Advantage HMO, HMO SNP, PPO, PPO SNP and PFFS organizations. Calls to QWIS will be routed to a licensed agent who can provide you with further information about the insurance plans offered by one or more third-party partners of QWIS. Each of the organizations they represent has a Medicare contract. Enrollment in any plan depends on contract renewal.

Availability of benefits and plans varies by carrier and location and may be limited to certain times of the year unless you qualify for a Special Enrollment Period. QWIS does not offer every plan available in your area. Any information provided is limited to those plans offered in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Deductibles, copays, coinsurance, limitations, and exclusions may apply.

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