Clarifying “Free” Screening Colonoscopies for Medicare Patients

Clarifying “Free” Screening Colonoscopies for Medicare Patients

I’m re-posting this article by Maria Selor. She’s the Supervising Attorney at the Elder Law Center in Wisconsin and wrote this article early this summer…

On Jan. 1, 2011, the preventative services provision of the Affordable Care Act was extended, making all Medicare patients eligible for free, important preventive services – including colonoscopies. However, not all colonoscopies are created equal, and this could impact whether it is truly without cost to you. This article explains what you should be aware of when receiving this important and life-saving test.

Screening Colonoscopy vs. Diagnostic Colonoscopy
The free Medicare exam only covers screening colonoscopies – not diagnostic colonoscopies. A screening colonoscopy is a procedure performed on a patient of screening age in order to find colon polyps or cancer. A colonoscopy that is performed in order to explain symptoms (e.g. blood in stools, change in bowel movements, etc) is called a diagnostic colonoscopy, which is not covered under the Affordable Care Act. Patients are usually fully liable for at least 20% (and maybe more) of the cost related to a scheduled diagnostic colonoscopy.

There are some cases where a scheduled screening colonoscopy can become a diagnostic colonoscopy, and in those cases a patient becomes responsible for any out-of-pocket costs related to their deductible, co- insurance or co-pays for standard costs like physician and facility fees. A screening colonoscopy becomes a diagnostic colonoscopy when a physician removes a polyp or takes a biopsy during the procedure. For Medicare patients, a family history of colon cancer or polyps will not automatically transform a screening colonoscopy into a diagnostic one. Some private insurers, however, will do this.

Beware! Related Services Not Always Covered
Medicare patients who are eligible to have a colonoscopy screening will pay no deductible, co-pay or co-insurance. However, please be forewarned – Patients may still be responsible for other services, such as anesthesia or medication, associated with the procedure. Some of those who have taken advantage of the “free services,” have been unpleasantly surprised to receive hefty bills. If you receive a bill after a “free” Medicare exam, contact the Elderly Benefit Specialist in your county immediately. He or she can help you determine if these charges are allowable.

How often is it covered?
Medicare rules dictate how often you can get a free screening colonoscopy. If you get the test sooner that the time periods listed below, you will likely be fully responsible for the cost.

  • Fecal Occult Blood Test: Once every 12 months.
  • Flexible Sigmoidoscopy: Generally, once every 48 months, or 120 months after a previous screening colonoscopy for people not at high risk.
  • Screening Colonoscopy: Generally once every 120 months (once every 24 months if you’re at high risk), or 48 months after a previous flexible sigmoidoscopy.
  • Barium Enema: Your doctor can decide to use this test instead of a flexible sigmoidoscopy or colonoscopy. This test is covered every 24 months if you are at high risk for colorectal cancer and every 48 months if you aren’t at high risk.

How do I qualify?
A Medicare patient can qualify for a screening colonoscopy if they:

  1. Are of the recommended screening age (for people of average risk = age 50 or over, though recent studies indicate that African-Americans may need to start screening at age 45.)
  2. Do NOT have any symptoms
  3. Do NOT have personal history of colon polyps or colon cancer

A Medicare patient can still qualify for a screening colonoscopy despite having a family history of colon cancer or colon polyps.

Costs: Screening Colonoscopy

  • Clarifying “Free” Screening Colonoscopies for Medicare Patients
    $0 annual deductible for procedure
  • $0 co-insurance for procedure

Costs: Diagnostic Colonoscopy

  • $0 annual deductible for procedure
  • 20% co-insurance must be paid for procedure

Why Should I Get a Screening Colonoscopy?
Colorectal cancer is the third most commonly diagnosed cancer and the 3rd leading cause of cancer death in both men and women in the US. The great majority of these cancers and deaths could be prevented with early screening. This is because most colorectal cancers develop from
adenomatous polyps. Polyps are noncancerous growths in the colon and rectum. Detecting polyps through screening and removing them can actually prevent cancer from occurring. Furthermore, being screened at the recommended frequency improves the chance that colorectal cancer will be detected at an earlier stage, when it is more likely to be cured by surgery alone, the surgical procedure is less extensive, and the recovery is much faster.

(statistics excerpted from AMERICAN CANCER SOCIETY, Colorectal Cancer Facts & Figures 2008-2010.)

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.