Three Times Your Free Medicare Colonoscopy Could Cost You

Retirement

Earlier this year, a family member had a screening colonoscopy. He’d seen the news stories about the Affordable Care Act mandating no out-of-pocket costs, such as co-pays or a deductible. So if this test is supposed to be “free,” why did he get a bill? This isn’t the first time I’ve heard of people receiving bills for this procedure. (Full disclosure: That even happened to me.)

Medicare covers a colonoscopy with no Part B deductible, copayment, or coinsurance when the test is done for screening:

  • Once every 2 years for those at high risk
  • Once every 10 years for those who are at average risk, and
  • Four years after a flexible sigmoidoscopy for those who are at average risk.

When there are twists to the rules, there can be cost-sharing as can happen in the following three situations.

The physician removes a polyp or tissue for a biopsy.

Medicare covers a screening colonoscopy, a test performed to check that the person’s health is on track and to identify whether any additional testing is necessary. When the doctor removes a polyp or tissue, the test becomes diagnostic, to confirm or eliminate potential diagnoses. In that case, a 15% Part B coinsurance applies, but not the Part B deductible.

A high-risk individual has a colonoscopy two years in a row.

Medicare defines high risk of developing colon cancer as someone who has a family history of the disease, has had inflammatory bowel disease, or has had colorectal cancer or colorectal polyps. These individuals qualify for a free screening every two years. If a high-risk person has the procedure every year, Medicare deems this not to be medically necessary and will not cover the procedure.

The doctor who performs the procedure is out-of-network.

This is an issue for those who elected Medicare Advantage. Using an out-of-network physician can cost the plan member. How much depends on the type of plan.

A health maintenance organization (HMO) plan will pay only for routine (non-emergency) services in-network. It can charge the patient the full cost for an out-of-network screening colonoscopy.

A preferred provider organization (PPO) plan will cover out-of-network services. But pay attention to these two facts. One, the physician has no obligation to see out-of-network patients; and two, the services can cost more, sometimes a percentage of the entire cost.

More Important Points about Diagnostic Colonoscopies

  • In- and out-of-network physicians are not a concern for those who have Original Medicare (Part A and Part B), with or without a Medigap policy (Medicare supplement insurance). They should choose a physician who accepts Medicare assignment.
  • There are some high-risk individuals with significant medical issues who need colonoscopies more frequently than every two years. Medicare will cover these as medically necessary diagnostic procedures. The 20% Part B coinsurance will apply but not the deductible.
  • A Medigap plan (Medicare supplement insurance) will cover the Part B coinsurance.
  • Instead of the coinsurance, Medicare Advantage plans can charge a copayment for diagnostic colonoscopies. Check the plan’s Evidence of Coverage or talk with a plan representative.
  • Medicare Advantage plans may require prior authorization for diagnostic colonoscopies.

Mention “colonoscopy” to a group of seniors and you’ll likely get a collective groan. It is not something they look forward to or want to do. However, it is definitely worth the time. A recent study on the benefits of colonoscopy screening, published in the New England Journal of Medicine, estimated a 31% decrease in the risk of colorectal cancer and a 50% decrease in colorectal cancer–related death. With statistics like these, can a colonoscopy be any more traumatic than seeing a dentist for teeth cleaning and examination? Both are extremely beneficial. And with a little knowledge, you won’t experience any sticker shock.

Articles You May Like

Hugo Boss shares plunge 9% as firm cuts 2024 guidance amid slumping China demand
Citadel’s Ken Griffin buys a stegosaurus for $45 million in a record auction sale
Global tech outage hits financial services companies, including Charles Schwab
In the face of trade tensions, China says it will focus on its own economy
IRS Finalizes Guidance On Treatment Of Inherited IRAs

Leave a Reply

Your email address will not be published. Required fields are marked *