Does Medicare Cover Cologuard?

Cancer is among the leading causes of death in the United States, and according to the American Cancer Society, colorectal cancers account for nearly 150,000 new cancer cases each year. While some colon and rectal cancers have a high level of treatment success, the key to beating these types of cancers is often to catch them early.

For most people, early detection can be done through a colonoscopy procedure along with other imaging studies.

Medicare Benefits Solutions

Jan 10, 2022

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Unfortunately, a colonoscopy procedure is invasive and may make patients uncomfortable. Even though someone undergoing a colonoscopy is sedated, the procedure can have side effects that include pain and the potential for internal injury.

To add to this, the preparation for a colonoscopy can involve fasting and the use of specialized laxative medications to cleanse the colon. Thankfully, modern medicine has an answer to these problems through the use of testing solutions like Cologuard.

What is Cologuard?

Cologuard is an at-home test kit that is used to determine whether a person may have colorectal cancer. The test is only available through a prescription, and the makers of Cologuard, Exact Sciences Corporation, state that the potential for false positives and false negatives exists. As a result, people who receive a positive result from a Cologuard test are encouraged to follow up with their doctors for further investigation. Those individuals who are at high risk for colorectal cancer that receive a negative test are encouraged to do the same.

This process is made simpler due to Cologuard working in concert with your healthcare provider. When you use your test kit, you collect a sample at home and send it to Cologuard’s lab for analysis. From there, Exact Sciences Corporation will send the results to your healthcare provider who can then discuss them with you and provide further instruction.

Does Medicare Cover Cologuard?

Because the potential for developing colorectal cancer increases with age, older Americans are encouraged to have a colon cancer screening completed according to the schedule recommended by their physicians. Thankfully, Medicare does provide benefits for colon cancer screening through Part B, the outpatient benefit.

Medicare benefits cover traditional colonoscopy screening services once every 120 months for most Medicare recipients. If you’ve had a flexible sigmoidoscopy, Medicare will provide coverage for a traditional colonoscopy screening 48 months after your last screening. If you fall into a high-risk category, you may receive a colonoscopy once every 24 months. During your screenings, any services rendered to remove polyps or other tissue may be billed at the standard 20% cost typically associated with Medicare Part B benefits.

According to Exact Sciences Corporation, Medicare covers Cologuard with no co-pay or deductible cost for Medicare recipients age 50 to 85. Some exclusions may apply, so it is recommended to check with your Medicare benefits plan manager for details about the specific coverage provided by your plan.

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Medicare Advantage Coverage and Cologuard

Medicare Advantage plan recipients should be able to receive the same benefits as Original Medicare recipients; however, Medicare Advantage plans may offer access to a larger array of colorectal cancer screening options. In addition to covering Cologuard, you may be able to seek screening services from a wider network of medical service providers under a Medicare Advantage plan.

Your specific Medicare Advantage plan may also offer access to additional services related to preventing colon cancer, including nutrition and wellness classes. Because each plan is unique and each provider determines its own additional offerings, you will need to consult with your plan manager for details.

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