For many, their insurer must cover the entire cost of colorectal screenings. There are exceptions, so talk with your insurer before scheduling an exam.

Story by: Kim Huston on April 5, 2021

The American Cancer Society recommends that people at average risk of colorectal cancer begin regular screening at age 45. People at higher risk for colorectal cancer should talk with their doctor about whether starting screening earlier might be right for them. While you may know that you need a colorectal cancer screening, you may be wondering whether you’ll have to pay for it.

Federal law requires private health insurance plans to cover colorectal cancer screenings

The Affordable Care Act (ACA) requires insurance companies to cover the total cost of colorectal cancer screenings for people ages 45 to 75 with no out-of-pocket cost. However, this rule doesn’t apply if the plan was created before the ACA was made a law (Sept. 23, 2010) — a “grandfathered plan.” You can find out your health plan’s status by contacting your insurance company or the benefits manager or human resources department if your employer provides your insurance.

How your health insurance classifies screenings

It’s also important to know that insurance companies may classify colonoscopies differently depending on whether the provider is checking for specific issues or conditions rather than performing a routine colon cancer screening. There are two categories:

• Screening: This is a colonoscopy or other colon cancer screening to check for colon cancer. The ACA requires coverage of these routine screenings.
• Diagnostic: This is a colonoscopy that checks for a specific issue. You may have to pay a deductible and/or copay. Here are a few examples of what is considered diagnostic:
  • Checking belly (abdominal) pain.
  • Checking for intestinal bleeding.
  • Checking for low red blood cell count (anemia).
  • Follow-up colonoscopies if you are high risk (private insurance).
  • If your provider finds and removes a polyp during a screening test, your screening may be reclassified as diagnostic (Medicare or grandfathered private insurance plans).

I’m between 45 and 75 and I have private insurance. Do I have any costs?

Many health plans cover the cost for a colonoscopy as a screening test. However, you may have to pay for some services, such as bowel prep medications, anesthesia or sedation, pathology costs or facility fees, depending on your health plan.

Before you schedule a colonoscopy, look at your health plan for any details. Check whether the providers you want to use are in your health plan’s network (in-network provider). If the providers aren’t in your health plan’s network (out-of-network provider), you may have to pay more out of your own pocket.

I have Medicare. Is it covered?

Medicare covers screening colonoscopies without requiring you to pay anything out-of-pocket. The program covers tests every 10 years, and every two years for high-risk patients. However, unlike with private health insurance, if a polyp is found during the screening, the procedure becomes diagnostic. That means you will need to pay a copay or other fees.

What can I do to control my costs?

Talk to your insurer and your provider before scheduling your colonoscopy. Getting this information ahead of time can help you avoid surprises when you get your bill. If you do have large bills afterward, you may be able to appeal the insurance company’s decision.

Ask your health plan:

• How much should I expect to pay (if anything) for a screening colonoscopy?
• What is my out-of-pocket cost if I go out of the network?
• Will my costs change if my provider finds and removes a polyp during the colonoscopy? If so, what would that cost be?