Colorectal cancer is a cancer that starts in the colon or rectum. Colorectal cancer screenings can detect conditions that may lead to colorectal cancer.
Eligibility
Medicare Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. covers different colorectal cancer screenings, each with separate eligibility requirements:
- Fecal occult blood test – once a year (every 12 months) if you are age 50+
- Flexible sigmoidoscopy – once every four years (48 months) if you are age 50+ and at high risk, or once every 10 years after a colonoscopy if you are age 50+ and not at high risk
- Colonoscopy – once every two years (24 months) if you are at high risk, or once every 10 years if you are not at high risk (but not within 48 months of a flexible sigmoidoscopy)
- Barium enema – once every two years (24 months) if you are age 50+ and at high risk, or once every four years (48 months) if you are age 50+ and not at high risk (but not within 48 months of a flexible sigmoidoscopy)
- Multi-target stool DNA tests – once every three years if you are age 50-85, show no symptoms of colorectal disease, and are not at high risk for developing colorectal cancer
- Blood-based biomarker tests – once every three years if you are age 50-85, show no symptoms of colorectal disease, and are not at high risk for developing colorectal cancer
Note: You do not have to be age 50+ to be eligible for a colonoscopy.
You may be at high risk for colorectal cancer if you:
- Have a family history of the disease
- Have had colorectal cancer or colorectal polyps
- Or, have had inflammatory bowel disease
Costs
If you qualify, Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. covers fecal occult blood tests, flexible sigmoidoscopies, and colonoscopies at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plans are required to cover these tests without applying deductibles, copayments, or coinsurance when you see an in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. provider and meet Medicare’s eligibility requirements for the service.
Barium enemas are covered at 80% of the Medicare-approved amount. When you receive the service from a participating provider, you pay a 20% coinsurance after you meet your Part B deductible. If you are enrolled in a Medicare Advantage Plan, contact your plan for cost and coverage information for barium enemas. Your plan’s cost-sharing may apply when seeing in-network providers.
During the course of your colorectal cancer screening, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.
Note: Some cancer screenings and other services are associated with specific genders in Medicare materials and rules but are covered regardless of the gender marker in your Social Security record, as long as the screening is clinically appropriate for you. Medicare has specific billing modifiers that your provider should use when submitting claims for services when the gender marker on your Social Security record could cause an incorrect coverage denial.