Medicare Coverage of Colorectal Cancer Screening
What It Is
Colorectal cancer screening
Medicare Part B covers four types of outpatient colorectal cancer screenings. How frequently a test is covered depends on the patient's medical history.
Colonoscopy: Medicare Part B covers one colonoscopy every ten years, but not within four years of a patient's previous flexible sigmoidoscopy colorectal cancer screening (see below). If a patient is at high risk for colorectal cancer, based on the patient's medical and family history, Medicare Part B can cover a colonoscopy once every two years.
Flexible sigmoidoscopy: Medicare Part B covers one flexible sigmoidoscopy every four years, but not within ten years of a patient's previous colonoscopy. Medicare Part B can cover a flexible sigmoidoscopy more frequently if a doctor determines that the patient is at high risk for colorectal cancer.
Barium enema: Medicare Part B covers a barium enema once every four years if the patient has not had a colonoscopy or flexible sigmoidoscopy within that time. For patients at high risk, Medicare Part B covers the test once every two years.
Fecal occult blood test: Medicare Part B covers a fecal occult blood test (a laboratory examination) as often as once a year.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for colorectal cancer screening, contact the plan directly.
What Medicare Pays
In 2010, Medicare Part B pays a different amount for each test.
Colonoscopy: If the screening procedure is performed in a doctor's office or clinic, Medicare Part B pays the full amount except for a coinsurance or co-payment. If the procedure is done in a hospital outpatient department or ambulatory surgical center, Medicare Part B pays 75 percent of the Medicare-approved amount.
Flexible sigmoidoscopy: Medicare Part B pays 80 percent of the Medicare-approved amount.
Barium enema: Medicare Part B pays 80 percent of the Medicare-approved amount.
Fecal occult blood test: Medicare Part B pays the full cost.
Beginning January 1, 2011, Medicare Part B pays the full cost of all the above screening tests, regardless of where they're administered.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.