Three Times Your Free Medicare Colonoscopy Could Cost You

Earlier this year, a family member had a screening colonoscopy. He’d seen the news stories about the Affordable Care Act mandating no out-of-pocket costs, such as co-pays or a deductible. So if this test is supposed to be “free,” why did he get a bill? This isn’t the first time I’ve heard of people receiving bills for this procedure. (Full disclosure: That even happened to me.)

Medicare covers a colonoscopy with no Part B deductible, copayment, or coinsurance when the test is done for screening:

• Once every 2 years for those at high risk
• Once every 10 years for those who are at average risk, and
• Four years after a flexible sigmoidoscopy for those who are at average risk.

When there are twists to the rules, there can be cost-sharing as can happen in the following three situations.

The physician removes a polyp or tissue for a biopsy.

Medicare covers a screening colonoscopy, a test performed to check that the person’s health is on track and to identify whether any additional testing is necessary. When the doctor removes a polyp or tissue, the test becomes diagnostic, to confirm or eliminate potential diagnoses. In that case, a 15% Part B coinsurance applies, but not the Part B deductible.

A high-risk individual has a colonoscopy two years in a row.

Medicare defines high risk of developing colon cancer as someone who has a family history of the disease, has had inflammatory bowel disease, or has had colorectal cancer or colorectal polyps. These individuals qualify for a free screening every two years. If a high-risk person has the procedure every year, Medicare deems this not to be medically necessary and will not cover the procedure.

The doctor who performs the procedure is out-of-network.

This is an issue for those who elected Medicare Advantage. Using an out-of-network physician can cost the plan member. How much depends on the type of plan.

A health maintenance organization (HMO) plan will pay only for routine (non-emergency) services in-network. It can charge the patient the full cost for an out-of-network screening colonoscopy.

A preferred provider organization (PPO) plan will cover out-of-network services. But pay attention to these two facts. One, the physician has no obligation to see out-of-network patients; and two, the services can cost more, sometimes a percentage of the entire cost.

More Important Points about Diagnostic Colonoscopies

• In- and out-of-network physicians are not a concern for those who have Original Medicare (Part A and Part B), with or without a Medigap policy (Medicare supplement insurance). They should choose a physician who accepts Medicare assignment.
• There are some high-risk individuals with significant medical issues who need colonoscopies more frequently than every two years. Medicare will cover these as medically necessary diagnostic procedures. The 20% Part B coinsurance will apply but not the deductible.
• A Medigap plan (Medicare supplement insurance) will cover the Part B coinsurance.
• Instead of the coinsurance, Medicare Advantage plans can charge a copayment for diagnostic colonoscopies. Check the plan’s Evidence of Coverage or talk with a plan representative.
• Medicare Advantage plans may require prior authorization for diagnostic colonoscopies.

Mention “colonoscopy” to a group of seniors and you’ll likely get a collective groan. It is not something they look forward to or want to do. However, it is definitely worth the time. A recent study on the benefits of colonoscopy screening, published in the New England Journal of Medicine, estimated a 31% decrease in the risk of colorectal cancer and a 50% decrease in colorectal cancer–related death. With statistics like these, can a colonoscopy be any more traumatic than seeing a dentist for teeth cleaning and examination? Both are extremely beneficial. And with a little knowledge, you won’t experience any sticker shock.