Medicare will cover Cologuard. Most people with Medicare won’t be responsible for co-insurance if they get a Cologuard kit. Reaching the next stage of life presents new screenings that you should talk to your doctor about. One of several options is Cologuard; however, your doctor or healthcare provider must give you a prescription.
How Often Does Medicare Pay for the Cologuard Test?
Part B will cover the Cologuard test once every three years if you meet the following criteria.
- At average risk
- Age 50-85
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 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; beneficiaries might be responsible for paying coinsurance or co-payments. Look over your plan, make sure you have a good understanding of what type of insurance you have, and what service options your plan covers for colorectal screening, including Cologuard.
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 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 the majority of private health insurance providers.
What are the Screening Guidelines for Cologuard Under Medicare?
The U.S. Preventative Services Task Force guidelines (USPSTF) for screening for colorectal 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. All of which, suggest stool DNA tests (like Cologuard) for the detection of colorectal cancer.
Does Medicare Advantage Cover Cologuard?
Beneficiaries with Medicare Advantage plans or other insurance plans besides Medicare may need to come out-of-pocket for some expenses. Any Medicare member and those with other insurance types whether private or public should contact their insurance plan provider about coverage.
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. They’re 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 they’re not participating.
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. Members have qualified for a 100% discount.
How to Get Medicare to Cover Cologuard 100%
Of course, there are some exceptions that will apply. No two situations are identical. Your insurance plan provider will confirm the costs. You can contact Medicare about how they cover Cologuard in your state.
Prior to 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.
Also, contacting a broker at the phone number above can 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.