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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

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Table of Contents:

    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.

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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.

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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.

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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.

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. U.S. Federal Government Medicare Coverage Database. Accessed July, 2023.
    https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=277
  2. U.S. Federal Government Medicare on Colonoscopy Coverage. Accessed July, 2023.
    https://www.medicare.gov/coverage/colonoscopies
  3. American Cancer Society. Accessed July, 2023.
    https://www.cancer.org/cancer/types/colon-rectal-cancer/about/key-statistics.html
Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

20 thoughts on "Does Medicare Cover Cologuard"

    1. Sara, great question! If you meet the criteria, Cologuard is typically covered by Medicare once every three years.

      1. Alice, criteria for Cologuard is the following: At average risk, Age 50-85, and Asymptomatic
        If you meet the criteria, you will be able to receive one test every 3 years.

  1. I had a cologuard 6/2021 (it was NORMAL) and scheduled to get a colonoscopy 2/022. Due to low iron and some bleeding. Will medicare pay for the colonoscopy?

    1. Dana, great question! Medicare will pay for the colonoscopy; however, you could be required to pay coinsurance or deductible as this would be a diagnostic test due to the bleeding and low iron.

    1. Hi Terri! Since Medicare Advantage varies from plan to plan, you would need to reach out to the carrier directly to find out if it’s covered.

  2. Does a standard guiac test for occult blood in the stool (giving a stool sample to your doctor), count as a screening, if it was done 1 year prior to a Cologuard screening? Would Medicare still cover the Cologuard test?

    1. Hi Leonora! If the test was done as a colon cancer screening, then Medicare won’t cover any other colon cancer screening done within three years of the last screening. The only exception is if you’re high-risk. If you’re considered high-risk, Medicare will cover a screening every two years. I would reach out to your doctor and ask since it depends on how they billed Medicare for the initial test of your stool.

  3. In one place it says Medicare will pay for the Cologuard test once every 3 years and in the above reply it says they pay for one each year. Which is correct?

    1. Hi Linda! Thank you so much for pointing that out. You are correct, it’s every 3 years. Medicare will cover a colon screening every 2 years if you are at high risk.

    1. Hi Whiteford! The concern is those over 85 are at higher risk of colon cancer. This Cologuard test is meant for those who are not high-risk. That’s why there’s a cutoff age.

  4. I just received a $665.00 bill for a cologuard test ordered by my doctor. I’m 68 with average to low risk. Medicare declined paying for the test. My next screening is in 3 years. I thought the test was covered by Medicare.

    1. Hi Debra! I would reach out to Medicare directly to find out why they declined to pay for the test. CMS does state that Cologuard is covered under Part B. It could be something as simple as the billing department from your physicians office used the wrong CPT code.

  5. I just received notice that Medicare will not pay my coloquard test…im 71 Medicare n aarp..I had a different test like coloquard a few months ago but my gi dr ordered coloquard said better..I am afraid of colonosopy because of scar tissue from previous surgeries…

    1. Hi Sandra! If you had a test a few months ago to screen for colon cancer, that’s probably why Medicare declined the test. Medicare will only pay for a screening once every 3 years. They will pay for a screening once every 2 years if you are high-risk.

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