Medicare Coverage of Colon Cancer

Jory Cross by Jory Cross | Licensed since 2012
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This article was updated on: 09/12/2018

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According to the Centers for Disease Control and Prevention (CDC), the risk of developing colon cancer increases dramatically as people age. More than ninety percent of patients were 50 years of age or older when they were first diagnosed. Besides age, other risk factors include an inflammatory bowel disease, a family or personal history of colorectal disease, and certain genetic disorders.

The CDC also cautions that some lifestyle factors may contribute to an increased risk. These include a diet low in fiber and produce; obesity; use of alcohol and/or tobacco; and a lack of physical activity. Because the risk of developing this kind of cancer increases with age, you may want to explore Medicare coverage of colon cancer tests and treatments.

Medicare coverage of colon cancer screenings

Medicare Part B may cover a variety of different kinds of tests for colon cancer, each requiring certain criteria to be covered. Doctors might consider age, risk factors, and results of other tests when deciding upon an appropriate type of screening. Note that your doctor must accept Medicare assignment and deliver services in a Medicare-approved facility.

  • Barium enema: Medicare covers one barium enema every four years (48 months) for beneficiaries over 50. This screening is covered every two years (24 months) for those with at high risk for colorectal cancer, if your doctor orders this screening instead of a flexible sigmoidoscopy or colonoscopy. Your payment under Part B is 20% of the Medicare-approved amount for this service. If you’re an inpatient in a hospital setting, you also have a copayment under Medicare Part A.
  • Colonoscopy: If you don’t have other risk factors, a colonoscopy is generally covered every 10 years (120 months). Medicare beneficiaries considered at high risk for colorectal cancer can get covered every two years (24 months). If you’ve had a flexible sigmoidoscopy, a colonoscopy is covered every four years (48 months). If the doctor accepts Medicare assignment, you pay nothing under Medicare Part B unless the screening results in a biopsy, or includes removal of a polyp or lesion*.
  • Fecal occult blood test: Patients with Medicare Part B who are over 50 can get coverage for this test every 12 months. This test, which checks a stool sample for blood, is fully covered with a referral from a doctor, nurse practitioner, physician assistant, or clinical nurse specialist.
  • Multi-target stool DNA screening: Beneficiaries can expect Medicare coverage every three years (36 months) if they meet certain conditions. These include an age between 50 and 85; an average risk of developing colon cancer; no symptoms of colorectal disease; and no personal or family history of colorectal diseases. With Medicare Part B, this test is 100 percent covered.
  • Flexible sigmoidoscopy: Medicare generally covers this screening for beneficiaries once every 10 years after having a previous colonoscopy. Medicare covers this screening for beneficiaries who are at least 50 once every 48 months after a previous flexible sigmoidoscopy or barium enema. Original Medicare fully covers this test as long as the doctors accept Medicare assignment; see the note below.*

* Note: In some cases, your health-care provider may perform a biopsy or remove a polyp or lesion during or immediately following your colonoscopy or flexible sigmoidoscopy screening. In this case, you might pay a copayment or coinsurance, but the Medicare Part B deductible doesn’t apply.

Medicare coverage of colon cancer treatments

Original Medicare coverage of colon cancer treatments depends on the type of treatment. Medicare Part A is hospital insurance, and covers a portion of your costs as a hospital inpatient. Medicare Part B is medical insurance, and may cover outpatient treatment related to colon cancer.

It’s worth noting that Original Medicare (Part A and Part B) includes limited prescription drug coverage. Part A may cover prescription drugs you receive as an inpatient, while Part B may cover chemotherapy in an outpatient setting. However, if your doctor prescribes medications for you to take at home, Original Medicare generally doesn’t cover them. If you need prescription drug coverage, you may want to sign up for either a Medicare Advantage Prescription Drug plan (described below) or a stand-alone Medicare Part D Prescription Drug Plan.

Medicare Advantage plans (offered by private, Medicare-approved insurance companies) include the same coverage as Original Medicare, Part A and Part B (except hospice care, which Part A still covers), and often include additional benefits such as prescription drug coverage. A Medicare Advantage Prescription Drug plan can provide all your Medicare coverage in a single plan. You still need to continue paying your Part B premium, in addition to any premium the Medicare Advantage plan may charge.

Medigap (Medicare Supplement) plans are also offered by private insurance companies and can help you pay your out-of-pocket costs for services covered under Original Medicare.

If you have a Medicare Advantage plan or a Medicare Supplement plan, you may want to call your health insurance company or consult your policy for more information. If you want to know more about Medicare plan options, you can call on me for help.

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Source: Centers for Disease Control and Prevention website.

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