Medicare will cover Cologuard for Medicare beneficiaries. Most people with Medicare won’t be responsible for a co-insurance if they get a Cologuard kit.
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.
Reaching the next stage of life presents new screenings that you should talk to your doctor about. Ask what colorectal cancer screening option the best choice. One of several options is Cologuard; however, your doctor or healthcare provider must give you a prescription.
Decisions about coverage of Cologuard for Medicaid plans depends on your state of residency. Each state may have different rules and regulations about coverage.
Cologuard: Will Medicare Cover
Medicare doesn’t need to follow the professional guidelines of either agency. However, Medicare has chosen to cover the costs of Cologuard as an option. Medicare likes the current state of the science and proof that is available.
Again, keep in mind, Medicare Advantage or other private insurance plans don’t have the same coverage as Original Medicare. If you have private insurance or a Medicare Advantage plan contact your plan provider to discuss coverage.
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 co-insurance 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.
What is Cologuard
Exact Sciences produced a non-invasive, stool DNA test. This test was created for the analyzation of the presence of blood and some DNA mutations in a person’s stool sample.
Sometimes, the presence of blood or DNA mutations can be a sign of cancer and/or precancerous polyps. Part of the body’s natural digestive process is the continuous release of DNA cells into the stool.
While there are at-home screening tests for detecting blood in the stool out on the market, Cologuard offers something more. Cologuard tests have an additional analysis for detecting abnormal DNA, these abnormalities can suggest you might have a tumor or polyp.
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 Medicaid Cover Colorguard
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 with 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 Cologuard 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.
Tips to Remember
After you’ve taken the test, if it’s positive – you can prepare for a colonoscopy. For negative results, you should still do a routine screening using Cologuard once every three years and Medicare will cover the check.
When providing a stool sample for screening, there are no dietary restrictions; you can eat whatever you’d like!
Any person experiencing diarrhea, blood in their urine, bleeding hemorrhoids, bleeding cuts, or wounds on hands, rectal bleeding or menstruation should not give a stool sample to Cologuard.
For those that do provide samples, make sure you follow the directions! Your stool is time sensitive, in this case anyway. The laboratory will need to process a patient’s sample within a 72-hour window.
Depending on the type of insurance will determine the price for the Cologuard blood test, for some, it may be higher or lower. 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 using Cologuard 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, should be covered by the majority of private health insurance providers.
Get Help to Cover Medicare and Cologuard
Of course, there are some exceptions that will apply. No two situations are identical. Your insurance plan provider will confirm the costs of Cologuard. You can contact Medicare about how they cover Cologuard in your state.
Prior to Cologuard or any colorectal or medical screening test, you should understand your coverage and what out-of-pocket expenses you’ll be responsible for. Contact your Medicare agent or insurance provider and ask before the testing.
Cologuard professional’s “highly encourage” their patients that receive a bill after using Cologuard to call their Customer Care Center. Although, patient’s responsible for an out-of-pocket expense from Cologuard can use the number to discuss appeal support with one of their representatives.
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.