Does Medicare Cover Cologuard

Summary: Cologuard is an important screening tool to help prevent colorectal cancer. Seniors are at higher risk for this disease and may be wondering if Medicare covers Cologuard. Find out what you need to know here. Estimated Read Time: 7 mins

Table of Contents:

1. 1. What is Cologuard?
   2. How is Cologuard Covered by Medicare?
   3. How Often Does Medicare Pay for the Cologuard Test?
   4. Does a Medicare Supplement Plan Cover Cologuard?
   5. Does Medicare Advantage Cover Cologuard?
   6. How Much Would Cologuard Cost with Medicare Coverage?
   7. What are the Screening Guidelines for Cologuard Under Medicare?
   8. Does Medicare Cover a Colonoscopy After Cologuard?
   9. Other Colorectal Cancer Screenings Covered by Medicare
   10. Does Medicaid Cover Cologuard?
   11. Understanding Medicare Coverage of Cologuard

Medicare will cover Cologuard if certain requirements are met. This means most Medicare beneficiaries won’t be responsible for out-of-pocket costs if they get a Cologuard kit and meet the requirements.

Colorectal cancer is a serious disease that could be fatal if not caught early. According to the American Cancer Society, an estimate of over 100,000 new cases of colorectal cancer will be diagnosed in the United States this year and it is the third leading cause of death in the U.S. in both men and women. It is most frequently diagnosed in those ages 65-74, so seniors are most at risk for colorectal cancer. Fortunately, if detected early, colorectal cancer has an over 90% survival rate.

There are multiple preventive screenings for detecting colorectal cancer, and Medicare generally will cover them. Cologuard is a more recent screening tool seniors can use to lessen their risk of developing colorectal cancer. Below, we review how and when Medicare covers Cologuard.

What is Cologuard?

Cologuard is a take-home screening test for the detection of colorectal cancer. It was approved by the U.S. Food and Drug Administration (FDA) in 2014, and it is currently the only FDA-approved home screening test for colorectal disease.

Even though Cologuard is a take-home testing kit, you will still need a prescription from your healthcare provider to obtain a test. Cologuard is not available over the counter. You would also need to go to the Cologuard website and print out a form to give to your doctor before they can give you a prescription.

Once your doctor fills out a prescription, your Cologuard kit will be sent to you by mail. The testing kit includes a collection bucket, bracket, probe, set of beakers, a preservation solution for shipping, and a prepaid shipping label.

The Cologuard detection tool is a simple, non-invasive procedure that tests fecal matter to help determine if colorectal cancer is present. The Cologuard test is a combination of two fecal immunochemical tests. The first looks for blood in the stool, and the second looks for DNA indicating cancer cells.

All you have to do is collect a stool sample and send it off to Cologuard’s Exact Sciences Lab. At the lab, specialists will evaluate the sample for abnormal cancer cells and polyps in the digestive tract.

However, it’s important to note that Cologuard, or any other stool DNA test, is not a replacement for a much more thorough colonoscopy.

How is Cologuard Covered by Medicare?

Cologuard is covered by Medicare Part B as it’s a colorectal cancer screening test, and it falls under preventive service care. However, Medicare usually does not cover additional screenings if you receive an abnormal DNA stool result.

It’s also important to know that Cologuard, and other preventive colorectal cancer screening tests, have eligibility requirements for Medicare Part B to cover the costs. Only if beneficiaries meet all the criteria does Medicare cover Cologuard. These requirements are as follows:

• You must not show any signs or symptoms of colorectal disease
• You must be between the ages of 50-85
• You must not have a personal or family history of colorectal cancer, inflammatory bowel disease, or adenomatous polyps
• You must not have a family history of hereditary adenomatous polyps, hereditary nonpolyposis colorectal cancer, or familial adenomatous polyposis

How Often Does Medicare Pay for the Cologuard Test?

Medicare Part B will cover the Cologuard test once every three years if you are low to moderate risk for developing colorectal cancer and meet the aforementioned criteria.

You should have a good understanding of what will affect your screening for colorectal cancer. The Affordable Care Act requires insurance companies to abide by the U.S. Preventive Services Task Force (USPSTF) recommendations for coverage. Rated by the USPSTF, if a screening test has an A or B rating, private insurance providers are required to cover the price of the exam. They may not charge these patients a co-pay for this exam.

Medicare is exempt from this requirement, and beneficiaries might be responsible for paying coinsurance or co-payments. It’s a good idea to look over your plan and make sure you have a good understanding of what type of insurance you have. You should also see which service options your plan covers for colon and rectal cancer screening, including Cologuard.

Does a Medicare Supplement Plan Cover Cologuard?

Medicare Supplement plans (or Medigap plans) provide coverage alongside Original Medicare (Medicare Part A and Part B). Medigap plans cover anything Original Medicare covers, and they only fill in any out-of-pocket cost gaps that Part A and Part B don’t cover. Since Cologuard is covered by Medicare Part B as preventive care, it comes at no cost to you under a Medicare Supplement plan.

Does Medicare Advantage Cover Cologuard?

Beneficiaries with Medicare Advantage plans (also called Medicare Part C), or other insurance plans besides Medicare may have some out-of-pocket expenses. Any Medicare member and those with other insurance types, whether private or public, should contact their insurance plan provider about coverage.

How Much Would Cologuard Cost with Medicare Coverage?

As long as you meet the previously mentioned eligibility factors, Medicare covers Cologuard 100%. You won’t have to meet any deductibles, and there are no copays for stool DNA testing.

However, if you aren’t eligible for Medicare Cologuard coverage, the test costs around $400-$600, and you may have to cover the expense completely out of pocket. Although, you can talk with your insurance company and request coverage for the test fees and lab.

You don’t 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 most private health insurance providers.

What are the Screening Guidelines for Cologuard Under Medicare?

The USPSTF guidelines for screening colon and rectal cancer do NOT include the testing of stool DNA. On the other hand, several agencies and societies do review these tests.

Agencies include the Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. These agencies suggest stool DNA tests (like Cologuard) to detect colorectal cancer.

Does Medicare Cover a Colonoscopy After Cologuard?

Medicare does cover a preventive colonoscopy every 24 months if you’re at high risk for colorectal cancer. However, if you receive positive Cologuard test results and need a diagnostic colonoscopy, Medicare will most likely bill you.

Medicare doesn’t cover 100% of diagnostic procedures, and the out-of-pocket costs can include deductibles, copayments, or coinsurance.

Other Colorectal Cancer Screenings Covered by Medicare

Medicare beneficiaries who don’t meet the requirements for Cologuard coverage can look into alternative options for screenings to help prevent colorectal cancer.

Besides the colonoscopy procedure, there are various other types of tests, including:

Fecal Occult Blood Test: Tests for blood in the stool. A stool sample is given and processed at home.

Sigmoidoscopy: An exam of the large intestine. A medical professional inserts a narrow, flexible tube with a tiny light and camera into the rectum to examine the lower colon. It is a minimally invasive procedure that generally takes about 15 minutes, and there is no sedation.

Barium Enema: An x-ray exam that can detect changes or abnormalities in your large intestine. It takes 30-60 minutes, and you are sedated during the procedure. However, unlike the other types of screenings, Medicare will only cover 80% of the approved costs instead of 100%.

Does Medicaid Cover 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.

If you don’t see your state, don’t worry because Cologuard is adding new states and plans all the time. Check back often, and if you’re considering canceling your test, call their Customer Care Center first. You can request more information about the financial assistance program that Exact Sciences offers. Some people on Medicaid have qualified for a 100% discount.

Understanding Medicare Coverage of Cologuard

Before any colorectal or medical screening test, you should understand your coverage and what out-of-pocket expenses you’ll be responsible for. Those with Medigap plans are usually protected against high out-of-pocket costs.

Contacting a licensed insurance agent at the phone number above can help you understand your Medicare coverage and save you money on out-of-pocket costs. However, if you can't call right now, we understand. Fill out an online rate form and discover your best plan options.

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