Does Medicare Cover Cologuard?
Yes, Medicare covers Cologuard, but only if you meet criteria that shows you are at low to average risk for developing colorectal cancer. Medicare Part B covers Cologuard tests every three years if prescribed by your physician and 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.
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What Is Cologuard?
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 is key to successfully catching and treating colon and rectal cancer, and offers a less invasive screening than a colonoscopy for people at low risk for developing colorectal cancer. Stool DNA tests works by testing fecal matter to determine if the sample contains abnormal cancer cells. Specialists can also evaluate the sample for polyps in the digestive tract. Keep in mind that Stool DNA tests do not replace a colonoscopy or other screening.
How Does Medicare Cover Cologuard?
Since Medicare classifies colorectal cancer screening (including Cologuard) as preventive care, is covered alongside other routine healthcare services through Medicare Part B. As Cologuard is primarily for those at low risk for colon cancer, people with a higher risk may choose a more thorough test, such as a colonoscopy.
Medicare typically does not cover the full cost of additional screenings for those who receive an abnormal Stool DNA test result.
To receive coverage for stool DNA tests, Medicare beneficiaries must meet all of the following criteria:
- You must not show any signs or symptoms of colorectal cancer.
- You must be between 50 and 85 years of age.
- You must not have a personal medical history of colorectal cancer, inflammatory bowel disease, or adenomatous polyps.
- You must not have a familial medical history of colorectal cancer, adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.
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 stool DNA tests a preventive diagnostic tool, the American Cancer Society do not recommend a higher frequency of Cologuard testing for low-risk individuals.
How Does Medicare Advantage Cover Cologuard?
Cologuard is covered for Medicare beneficiaries as a preventive screening under Medicare Parts A and B, so Medicare Advantage plans will also provide coverage under those terms.
However, as Medicare Advantage is offered by private insurance companies approved by Medicare, many plans include extended benefits. For example, some Medicare Advantage plans cover stool DNA tests more frequently than Original Medicare’s three-year requirement, as well as follow-up appointments and tests for those who need it.
Look into your Medicare Advantage plan’s details to see if your policy offers extended stool DNA test benefits, or speak with a trusted agent to find a plan that does.
How Much Would Cologuard Cost With Medicare?
As long as you meet eligibility requirements for the Cologuard test, it is 100% covered by both Original Medicare and Medicare Advantage. You do not need to meet any deductibles for coverage, and there are no copays for the test.
However, if you do not fall within the criteria for the stool DNA test — such as if you have a family history of colorectal cancer — Medicare may not provide coverage, and Cologuard costs roughly $400-$600 without insurance.
Those who do not meet requirements for stool DNA testing should seek alternative Medicare-covered colorectal cancer screening options. In addition, any follow-up care based on the results of your Cologuard screening may not be covered by Medicare.
Cologuard vs. Other Colorectal Cancer Screenings
Every three years for low to moderate risk
Stool sample taken at home and mailed in prepaid packaging to lab
Every two years for high risk; every 10 years for low to moderate risk
30-60 minutes; sedation; colonoscope insertion
Every 4 years for those who are at least 45 years old; every 10 years after colonoscopy
15 minutes; no sedation; sigmoidoscope insertion
Medicare covers 80% of Medicare-approved amount
Every 4 years if used instead of sigmoidoscopy or colonoscopy; every two years for high-risk
30-60 minutes; sedation; enema insertion and x-ray
Fecal Occult Blood Test
Every year for those who are at least 45 years old
Stool sample given and processed at home
Multi-target Stool DNA Test
Every 3 years for low to moderate risk
Stool sample taken at home and brought to lab
Computed Tomography (CT) Colonography
15 minutes; no sedation; scanned using CT machine
Healthcare providers commonly offer several colorectal cancer screenings, each with its own benefits and drawbacks. Traditional screenings, colonoscopies, offer varying degrees of diagnostic information and invasive techniques.
Most Medicare coverage includes any or all of these screenings for beneficiaries who are 45 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. That said, Cologuard is often preferred for its non-invasiveness among low-risk candidates who receive Medicare.
Note that only the Computed Tomography (CT) colonography, or virtual colonography, is not covered by Original Medicare at this time. However, some Medicare Advantage plans offer coverage for this procedure, so if you are interested in it, review your policy benefit details.
How Each Colorectal Cancer Screening Method Works
When deciding which screening method you should utilize, consider your personal risk level as well as your comfort level with each method’s procedure.
- Cologuard: This test is typically done at home using a kit provided by the doctor or laboratory, which includes a special container, prepaid mailing label, and instructions for collecting stool sample. Patients then mail the sample to a laboratory for analysis.
- Colonoscopy: During a colonoscopy, a flexible tube with a camera on the end is inserted into the anus and guided through the colon, allowing the doctor to look for abnormalities or signs of disease. If any polyps or other abnormalities are found, they can be removed during the procedure. The process typically takes about an hour, and patients are under sedation to minimize discomfort.
- Sigmoidoscopy: Like with a colonoscopy, a flexible tube with a camera on the end is inserted into the anus and guided through the sigmoid colon to look for abnormalities or signs of disease. Unlike a colonoscopy, which examines the entire colon, a sigmoidoscopy only examines the lower third of the colon. The procedure typically takes 10-20 minutes and is done without sedation, although a local anesthetic may be used.
- Barium Enema: During the procedure, liquid barium is inserted into the rectum through a small tube. The barium coats the inside of the colon, and X-ray images are taken. The doctor examines these X-rays to look for abnormalities. The process usually takes about 30-60 minutes and may involve changes in position to allow the barium to coat different parts of the colon.
- Fecal Occult Blood Test: This test looks for blood in the patient’s stool, which can be an indicator for colon cancer and other conditions. Like Cologuard, it is a test that uses a stool sample collected at home. Fecal occult blood test kits are provided by the doctor or laboratory, and includes a special test card and instructions for collecting and processing the stool sample. If blood is detected, further testing may be needed to determine the cause.
- Multi-target Stool DNA Test: This test is used to detect the presence of abnormal DNA in the stool, which can be a sign of colon cancer or other conditions. The test is typically done at home using a kit provided by the doctor or laboratory, which includes a special container and instructions for collecting a stool sample. The sample is then sent to a laboratory for analysis.
- Computed Tomography (CT) Colonography: Also known as a virtual colonoscopy, a CT scanner takes multiple X-ray images of the colon from different angles, which are combined to create a detailed 3D image of the colon that the doctor can examine. The process typically takes about 30 minutes to an hour. If any abnormalities are found during the procedure, further testing or a traditional colonoscopy may be needed. Keep in mind that unlike the other alternatives, CT colonographies are not currently covered by Medicare.
Putting It All Together
Medicare covers stool DNA test for those who are at low to moderate risk of colorectal cancer. This is a non-invasive test that can be done in the comfort of your own home, and allows you to assess your risk of developing colorectal cancer. Ideal Cologuard candidates are at least 50 years old and have no colorectal cancer symptoms or personal or family history of this disease.
Individuals at high risk for colorectal cancer, or a past diagnosis of adenomatous polyps, inflammatory bowel disease, or poor digestive tract health, should explore the other screening methods that Medicare covers, such as colonoscopies and barium enemas.
No matter your risk level, catching colon cancer early is critical. Early detection increases the chances of successful treatment and long-term survival.