Cologuard is a take-home screen test for colon and rectal cancer, which is one of the leading causes of cancer deaths globally. Colon and rectal cancer most often impact people 50 and older, with 90% of new cases appearing in this age group.
Early detection with kits like Cologuard is key to successfully catching and treating colon and rectal cancer, and thankfully, Medicare may cover it.
Does Medicare Cover Cologuard?
Medicare does cover Cologuard, but only under certain circumstances. Specifically, Medicare Part B–or the portion of Original Medicare that’s responsible for medical coverage–covers Cologuard tests every three years, provided you are under 85 years of age, show no signs of colorectal disease, and have no personal or family history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease.
Medicare Part B also only covers 100% of Cologuard costs when prescribed by a doctor in the Medicare network. Beneficiaries who meet all necessary criteria can take a Cologuard test through Medicare without using copays, coinsurance, or deductibles.
Does Medicare Advantage Cover Cologuard?
While Cologuard is covered for qualifying enrollees as a preventive screening under Medicare parts A and B, Medicare Advantage plans are subject to the terms of their particular carrier, as Medicare Advantage is an optional add-on to Original Medicare that can be purchased through a private insurance carrier.
Most Medicare Advantage plans do offer at least partial coverage of Cologuard tests; however, enrollees may be required to pay some out-of-pocket costs or meet other requirements.
How Does Cologuard Work?
Cologuard is an at-home colorectal cancer screening kit, which tests DNA taken from fecal matter to determine if the sample contains abnormal cancer cells. Specialists can also evaluate the sample for polyps in the digestive tract. Cologuard offers a less invasive screening than a colonoscopy for people at low risk for developing colorectal cancer.
Ideal Cologuard candidates are 50 or above, with no colorectal cancer symptoms or personal or family history of this disease. Cologuard does not replace a colonoscopy or other screening for individuals at high risk for colorectal cancer, or a past diagnosis of adenomatous polyps, inflammatory bowel disease, or poor digestive tract health.
Other Colorectal Cancer Screenings
Healthcare providers commonly offer several colorectal cancer screenings, each with its own benefits and drawbacks. Traditional screenings, including barium enemas, colonoscopies, and fecal occult blood tests, offer varying degrees of diagnostic information and invasive techniques.
Most Medicare coverage includes any or all of these screenings for recipients 50 years or older who are at moderate-to-high risk of colon cancer; however, a colonoscopy is considered the gold standard for accurate detection of colorectal cancer in high-risk patients. Cologuard may be preferred for its non-invasiveness among low-risk candidates who receive Medicare.
How Much is Cologuard with Medicare Coverage?
While Medicare covers 100% of Cologuard costs for recipients who meet certain criteria, there may be some out-of-pocket costs involved under some circumstances. Medicare Advantage policyholders should contact their carriers to confirm they meet the requirements to access a free Cologuard test.
Cologuard costs roughly $400-$600, though most Medicare recipients are not charged. You may owe a copay or coinsurance payment if your doctor recommends additional screenings, treatment, or follow-up care based on the results of your Cologuard screening that is not covered by Medicare.
What are the Screening Guidelines for Cologuard Under Medicare?
Medicare Part B covers Cologuard tests, provided enrollees meet all of the following criteria:
- Candidates must not show any signs or symptoms of colorectal cancer.
- Enrollees must be between 50 and 85 years of age.
- Candidates may not demonstrate a personal medical history of colorectal cancer, inflammatory bowel disease, or adenomatous polyps.
- Patients must not demonstrate a familial medical history of colorectal cancer, adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.
Since Medicare classifies colorectal cancer screening (including Cologuard) as preventive care, Cologuard is covered alongside other routine healthcare services through Medicare Part B.
How Often Does Medicare Pay for the Cologuard Test?
Medicare covers a Cologuard test every three years for people aged 50-85 with an average risk of developing colorectal cancer. As Medicare considers Cologuard a preventive diagnostic tool, the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society do not recommend a higher frequency of Cologuard testing for low-risk Medicare recipients.
People at an increased or high risk of colorectal cancer may choose a more thorough test such as a colonoscopy and start testing at 45 years old. The USPSTF recommends more frequent colonoscopies for this high-risk group. Medicare typically does not cover the full cost of additional screenings for these or other patients who receive an abnormal Cologuard result.