Story by: Kim Huston on April 5, 2021
The American Cancer Society recommends that people at average risk of colorectal cancer begin regular screening at age 45. People at higher risk for colorectal cancer should talk with their doctor about whether starting screening earlier might be right for them. While you may know that you need a colorectal cancer screening, you may be wondering whether you’ll have to pay for it.
Federal law requires private health insurance plans to cover colorectal cancer screenings
The Affordable Care Act (ACA) requires insurance companies to cover the total cost of colorectal cancer screenings for people ages 45 to 75 with no out-of-pocket cost. However, this rule doesn’t apply if the plan was created before the ACA was made a law (Sept. 23, 2010) — a “grandfathered plan.” You can find out your health plan’s status by contacting your insurance company or the benefits manager or human resources department if your employer provides your insurance.
It’s also important to know that insurance companies may classify colonoscopies differently depending on whether the provider is checking for specific issues or conditions rather than performing a routine colon cancer screening. There are two categories:
Many health plans cover the cost for a colonoscopy as a screening test. However, you may have to pay for some services, such as bowel prep medications, anesthesia or sedation, pathology costs or facility fees, depending on your health plan.
Before you schedule a colonoscopy, look at your health plan for any details. Check whether the providers you want to use are in your health plan’s network (in-network provider). If the providers aren’t in your health plan’s network (out-of-network provider), you may have to pay more out of your own pocket.
Medicare covers screening colonoscopies without requiring you to pay anything out-of-pocket. The program covers tests every 10 years, and every two years for high-risk patients. However, unlike with private health insurance, if a polyp is found during the screening, the procedure becomes diagnostic. That means you will need to pay a copay or other fees.
Talk to your insurer and your provider before scheduling your colonoscopy. Getting this information ahead of time can help you avoid surprises when you get your bill. If you do have large bills afterward, you may be able to appeal the insurance company’s decision.
Ask your health plan:
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