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Will Medicare Pay For Cologuard

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Does Medicaid Cover Cologuard

Insurance Coverage of Cologuard®

For the creators of Cologuard to submit claims to your state Medicaid plan for payment purposes, Exact Sciences Laboratories must be a Medicaid provider in your state. Theyre not on contract with Medicare in every state for instance, in New York, Cologuard is a preventative service for Medicaid members. Then, some states will allow Exact Sciences to contact directly Medicaid plans in the states theyre not participating.

If you dont see your state, dont worry because Cologuard is adding new states and plans all the time. Check back often, and if youre considering canceling your test, call their Customer Care Center first. You can request more information about the financial assistance program that Exact Sciences offers. Members have qualified for a 100% discount.

Does Medicare Cover Cologuard

Cancer is among the leading causes of death in the United States, and according to the American Cancer Society, colorectal cancers account for nearly 150,000 new cancer cases each year.

While some colon and rectal cancers have a high level of treatment success, the key to beating these types of cancers is often to catch them early. For most people, early detection can be done through a colonoscopy procedure along with other imaging studies.

TIP: Are you looking for a plan that includes labwork and other diagnostic testing services? Try our Medicare plan finder to help you find plans and compare them side-by-side.

Medicare Benefits Solutions

Will Medicare Help Pay For Cologuard

Earlier Cologuard was not covered by Medicare and most other insurance policies.

However, a few years back, the Centers for Medicare & Medicaid Services made an announcement that Cologuard would be covered by Medicare based on the CMS National Coverage Decision.

This decision has been of great benefit for the patients who are experiencing symptoms such as blood in stools, recurrent loose motions, and drastic weight loss that indicate the risk of colon cancer.

The announcement by CMC also mentioned that the patients who were already enrolled in Medicare would not have to bear the expenses of any co-insurance or co-pays if they obtain the Cologuard kit.

However, it is important to note that patients who have insurance plans other than Medicare such as Medicare Advantage may be responsible for some out-of-pocket expenses related to the Cologuard kit.

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How Much Does A Colonoscopy Cost With Medicare

Thanks to Medicare coverage for colonoscopy exams, a preventative test will be covered for Medicare beneficiaries. Medicare recipients who are at high risk for colorectal cancer are covered for colonoscopies once every 24 months. For all other beneficiaries, they are covered for one colonoscopy every 10 years.

Medicare considers you at high risk and will cover a colonoscopy every 24 months if you have:

  • A personal history of colorectal cancer
  • An inflammatory bowel disease
  • Adenomatous polyps
  • A close relative diagnosed with colorectal cancer or an adenomatous polyp
  • A family history of hereditary nonpolyposis colorectal cancer or familial adenomatous polyposis

Medicare also will cover a colonoscopy if you had a flexible sigmoidoscopy at least 48 months ago.

Does Medicare Require Preauthorization For Colonoscopy

Medicare Now Covers Stool DNA Screening Test Cologuard

When you receive a colonoscopy exam during your approved timeframe, Medicare will cover 100% of the cost as a screening procedure. Thus, you will not be responsible for paying for anything out-of-pocket for the service. Medicare will also cover this cost if you require anesthesia for your colonoscopy procedure.

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What Are The Different Types Of Colorectal Cancer Screenings And Eligibility Requirements For Each

The following are Medicare-covered colorectal cancer screening exams :

  • A fecal occult blood test is a lab test used to check stool samples for hidden blood. Original Medicare covers this test every twelve months if you are age 50 and older.
  • A screening colonoscopy is covered by Original Medicare as often as every 24 months for those at very at high risk, or once every 10 years if you are not at high risk. There is no minimum age requirement if medically-indicated by risk.
  • Cologuard is the brand name of a test that you might have seen on television. It is less invasive than colonoscopy, and is an alternative that your physician might recommend if you are at low risk for colon cancer. If so, it is a Medicare-covered test.
  • A flexible sigmoidoscopy is similar to a colonoscopy, but is much less widely recommended because it does not probe your entire colon. If ordered by your physician for a specific accepted indication, will be covered by Medicare.
  • A barium enema is an X-ray of the colon after it has been filled with barium. It is generally not used for screening. However, if ordered by your physician for a specific accepted indication, will be covered by Medicare.

Medicare Advantage plans cover these same colorectal cancer screenings without applying deductibles, copayments or coinsurance as long as you see an in-network provider and meet Medicares eligibility requirements for these services.

How Accurate Is The Cologuard Test

Cologuard can detect 92% of cancers but only 42% of large precancerous polyps.

Cologuard is better at detecting cancer than FIT , but the false positive rate is higher. Cologuard has a 13% false-positive rate, and that rate increases as people age.

Cologuard is less accurate than a colonoscopy at detecting polyps of any size. A colonoscopy can detect 95% of large polyps and Cologuard only 42%.

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Benefits Of The Cologuard Test

The Cologuard test has several benefits over other kinds of tests.

You can do the test at home, which cuts back on time in waiting rooms or in the hospital having an exam.

Some people are hesitant about having a colonoscopy because it generally requires some sedation.

Cologuard allows you to be screened without having any sedation or anesthesia. However, if your Cologuard test is atypical, it should be followed up with a colonoscopy.

Cologuard also doesnt require any preparation. You dont need to stop taking medications or fast before you take a Cologuard test. If covered by insurance, Cologuard costs significantly less than a colonoscopy.

The Cologuard test has some drawbacks, mostly involving its accuracy.

A 2018 research review shows that stool sample testing is not as accurate as colonoscopy when it comes to detecting precancerous polyps and lesions.

False positives can create a lot of unnecessary stress and worry while you wait for follow-up testing. The high levels of false positives associated with Cologuard make some doctors wary of the test.

False negatives or missing the presence of colon cancer or polyps are also possible. In a 2014 study, the false negative rate was higher for large polyps.

Since Cologuard testing is somewhat new, theres not any long-term data available on how this screening method will affect your long-term outlook if you do end up having colon cancer.

Keep in mind that there are other fecal testing kits available aside from Cologuard.

What Is A Colonoscopy

Some people are facing pricey medical bills after using popular at-home colon cancer test

A colonoscopy is an invasive procedure that may make patients uncomfortable. Even though someone undergoing a colonoscopy is sedated, the procedure can have side effects that include pain and the potential for internal injury.

To add to this, the preparation for a colonoscopy can involve fasting and the use of specialized laxative medications to cleanse the colon. Thankfully, modern medicine has an answer to these problems through the use of testing solutions like Cologuard.

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The Truth About Cologuard Tests

Cologuard spends millions advertising its colon cancer screening product, but itâs impossible for patients to get all the information they need in a TV commercial. Itâs true, Cologuard offers benefits of comfort and convenience, but the Cologuard test is not recommended by GCSA physicians as a replacement for a colonoscopy.

Colon cancer claims over 50,000 lives every year and is the 2nd most common cause of cancer death in the US. Colon cancer is preventable, treatable, and beatable but only with early and accurate detection.

Any colon cancer screening is better than no screening, but patients should know the pros and cons before making a final decision.

Different Colorectal Screening Tests Medicare Covers

Medicare covers five different types of colorectal screenings. The different tests are recommended for different patients based on age, frequency of testing and your risk for colorectal cancer.

In certain cases, you may have out-of-pocket expenses if the screening turns into a biopsy or tissue removal.

Colorectal Screenings that Medicare Covers

SCREENING TEST
  • Once every two years if you are at high risk
  • Once every four years if you are at high risk
Medicare covers 80 percent. You are responsible for a 20 percent copay for doctors services. You may also be responsible for hospital copayments or coinsurance. This screening is only covered if your doctor determines it has equal or greater screening value than a colonoscopy or sigmoidoscopy.

Colonoscopies and sigmoidoscopies are only considered screening tests so long as your doctor is looking for signs of colorectal cancer. If your doctor finds polyps or other growths and biopsies or removes them, the procedures become diagnostic tests.

The ACA does not require full coverage for diagnostic tests. Thats why you may have out-of-pocket costs if you have either of these procedures.

Its important to find out the cost of a colonoscopy, sigmoidoscopy or double-contrast barium enema so you can be prepared for possible out-of-pocket costs.

If youre getting a colonoscopy or sigmoidoscopy, also ask about the cost of biopsies and polyp removal to prepare for potential expenses.

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Colorectal Cancer Is The Third Leading Cause Of Death For Both Men And Women

While most frequently diagnosed among those ages 65 to 74, colorectal can also affect those younger than 50, and incidents of colorectal cancer in younger adults are increasing each year. However, according to recent data from the U.S. Preventive Services Task Force , more than 30% of eligible adults are not up-to-date with their screening.

Luckily, Medicare covers several preventive screenings that help detect cancer early, when treatment is most likely to be successful. One of these is Cologuard, an at-home screening test that can help catch colon and rectal cancer.

Read on to learn more about Cologuard Medicare coverage, as well as coverage for other colorectal cancer screening tests, why and how often to get screened, symptoms, and risk factors.

Medicare Coverage For Colorectal Cancer Screening

Colonoscopy VS Cologuard, Why Colonoscopy is Best

Medicare covers an initial preventive physical exam for all new Medicare beneficiaries. It must be done within one year of enrolling in Medicare. The Welcome to Medicare physical includes referrals for preventive services already covered under Medicare, including colorectal cancer screening tests.

If youve had Medicare Part B for longer than 12 months, a yearly wellness visit is covered without any cost. This visit is used to develop or update a personalized prevention plan to prevent disease and disability. Your provider should discuss a screening schedule with you for preventive services you should have, including colorectal cancer screening.

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Cologuard Test Vs Colonoscopy

While Cologuard and a colonoscopy can both be used as screening tests, they take two different approaches and provide different information.

Cologuard detects proteins that may be shed from colon cancer and polyps. When your doctor performs a colonoscopy, theyre trying to find the polyps themselves.

According to the , colonoscopy does carry a low risk of complications. These include reactions to sedatives or possible puncturing of your bowel. Cologuard carries no such risks.

On the other hand, a

Medicare .

If youre eligible for colon cancer screening and have insurance, you may be able to get Cologuard without any out-of-pocket expense.

If you dont have insurance, or if your insurance wont cover it, you may have to pay out-of-pocket. Its best to call the Cologuard customer care number to find out how much the test might cost for you.

How Much Is Cologuard With Medicare Coverage

Depending on the type of insurance will determine the price for the Cologuard blood test, for some, it may be higher or lower. The price of the test can range from $400-$600. Although, talking with your insurance provider can help you can request fees for the test and laboratory be covered.

You dont know unless you ask. More than 92% of all patients have a $0 out-of-pocket cost for testing. For eligible patients ages 50-75, with an average risk for colon cancer, without any symptoms, it should be covered by the majority of private health insurance providers.

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Colorectal Cancer: Risk Factors

Medicare pays for more frequent colonoscopies for people at high risk of developing colorectal cancer.

According to the Centers for Medicare & Medicaid Services, that means someone meets one or more of these criteria.

  • Has a personal history of colorectal cancer adenomatous polyps, a form of polyp that is benign but can become cancerous or an inflammatory bowel disease such as Crohns disease and ulcerative colitis.
  • Has a close relative a parent, sibling or child who has had colorectal cancer or an adenomatous polyp.
  • Has a family history of inherited syndromes linked to colorectal cancer, such as familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer, also known as Lynch syndrome.

Editors note: This article was originally published on July 17, 2015. It has been updated with the latest information regarding Medicare coverage in 2020.

Column By Joel Mekler: Medicare And Colonoscopy Coverage

Provider Minute: The Importance of Proper Documentation

How colonoscopies are billed can affect costs and insurance coverage.

I consider myself to be a pretty well-informed health care consumer. Over the years, Ive helped many people navigate the healthcare maze.

But even I recently experienced a gotcha moment that I will always remember.

Last January, I went for my colonoscopy. Generally, the procedure is recommended once every five to 10 years, depending on your risk of getting colorectal cancer. My doctor suggested I be screened every five years because I had a personal history of colon polyps.

I spoke with my doctors physician assistant a few weeks before the screening. He asked me for some preliminary information, like what medications I was taking and if I was experiencing any gastrointestinal issues. I did mention that I occasionally have constipation and some lower abdomen pain. The physician assistant said I was due for my next colonoscopy, so I scheduled the procedure the following month.

Boy, was I in for a surprise when I received bills from the surgeon, anesthesiologist, and pathologist. In addition, I received a facility fee.

I had expected that the procedure would be covered in full as part of my preventive benefits. My insurance company said the procedure was coded as diagnostic. Because of the way it was coded, I was now responsible for paying my deductible plus 15 percent coinsurance.

MEDICARE COVERAGE OF COLONOSCOPIES

You may be at high risk for colorectal cancer if you:

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Who Is A Candidate For Cologuard

1. Cologuard is intended for use with patients, age 50 years and older, at average risk who are typical candidates for Colorectal Cancer screening.

2. Cologuard costs $599 and must be ordered by a physician.

3. In TN Cologuard is covered in full by Medicare red/white/blue. Medicare advantage plans will cover Cologuard with a nominal co-pay.

4. Cologuard is covered by Medicare every 3 years.

5. Positive results should be followed by standard diagnostic colonoscopy.

Cologuard is ideal for Medicare patients that require screening examinations who are elderly, frail, or on anticoagulant medications.

What Colonoscopy Costs Does Medicare Cover

Medicare covers all costs associated with a colonoscopy screening for colorectal cancer so long as the doctor who does it accepts Medicare.

If the doctor removes polyps or other tissue during the procedure, Medicare will pay 80 percent of the Medicare-approved cost.

You will be responsible for the other 20 percent of costs. You will also be responsible for any copayment if the screening happens in a hospital setting. Your Medicare Part B deductible will not apply.

Medicare does not cover a CT colonography sometimes called a virtual colonoscopy.

Not all colonoscopies are for colon cancer screenings. Medicare may not fully cover these examinations. You should check with your doctor about the nature of your colonoscopy and with Medicare or your Medicare Advantage insurer about coverage and out-of-pocket costs.

Colonoscopies that may not be fully covered by Medicare include:

  • Diagnosing symptoms, including diarrhea and bloating.
  • Diagnosing the reason for blood in the stool or bleeding from the rectum.
  • Monitoring or diagnosing irritable bowel disease .

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Does Medicare Cover Diagnostic Colonoscopy Procedures

Diagnostic colonoscopies are when a polyp or other tissue is found or removed. Part B will cover some of your diagnostic colonoscopy but it may not be 100% covered.6

For example, you may have to pay 20% of the Medicare-approved amount of your doctors services. Also, if the diagnostic colonoscopy is performed in a hospital outpatient setting, you will likely pay a separate facility copayment.7

If you have a Medicare Advantage plan, you may have additional coverage for diagnostic colonoscopies. Contact your plan carrier to see what benefits may be available to you.

Who Needs A Colonoscopy

Cologuard, Home Screening Test For Colorectal Cancer, Available Through ...

The U.S. Preventive Services Task Force recommends that people at average risk of colorectal cancer should have regular colonoscopies starting at age 50. The American Cancer Society recommends people start screening at 45.

The USPSTF concluded that colonoscopies provide a substantial benefit to people aged 50 to 75. But it found that a colonoscopy may not be as beneficial to people 76 to 85 whove had previous screenings.

Colorectal cancer is most often diagnosed in people from 65 to 74 years old, and the average age of death from the disease is 73.

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