Does Medicare Cover Cologuard?
Key Takeaways
- Medicare Part B covers the Cologuard test once every three years for beneficiaries aged 50-85 who are asymptomatic and at average risk for colorectal cancer.
- Eligibility excludes individuals with a personal or family history of colorectal cancer, adenomatous polyps, inflammatory bowel disease, or hereditary cancer syndromes.
- Medicare Advantage plans must also cover Cologuard, though costs and requirements may vary by plan.
- Eligible beneficiaries pay no deductible, copay, or coinsurance for Cologuard, but a follow-up colonoscopy after a positive result requires meeting the Part B deductible ($257 in 2025) and/or paying 20% coinsurance.
Does Medicare cover Cologuard? The answer is yes, Medicare does cover Cologuard, but specific criteria surrounding age limits and personal and family health history must be met. Cologuard can be done conveniently at home, offering people a noninvasive option for colorectal cancer screening. This article delves into Medicare’s coverage for Cologuard, including eligibility requirements, coverage specifics, and associated costs.
What Is Cologuard?
Cologuard is an FDA-approved, noninvasive stool DNA test used to detect colorectal cancer and precancerous polyps. According to the National Cancer Institute, colorectal cancer is most frequently diagnosed among people aged 65-74. The good news is that when detected early, colon cancer is treatable. Preventative screenings are lifesaving, especially for seniors who are more likely to be diagnosed with colon cancer.
Cologuard works by analyzing a stool sample for specific DNA markers and traces of blood that may indicate the presence of cancer or advanced adenomas. The appeal of Cologuard is that beneficiaries can collect the sample from the comfort of their homes and send it to a laboratory for analysis.
However, it’s important to note that Cologuard does not replace a colonoscopy. If Cologuard results are positive, a follow-up diagnostic colonoscopy is typically necessary to confirm the findings.
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How Medicare Covers Cologuard
| Medicare Coverage | Coverage Cadence | Testing Process | |
|---|---|---|---|
| Cologuard | 100% covered | Every three years for low to moderate risk | Stool sample taken at home and mailed in prepaid packaging to lab |
| Colonoscopy | 100% covered | Every two years for high risk; every 10 years for low to moderate risk | 30-60 minutes; sedation; colonoscope insertion |
| Sigmoidoscopy | 100% covered | Every 4 years for those who are at least 45 years old; every 10 years after colonoscopy | 15 minutes; no sedation; sigmoidoscope insertion |
| Barium Enema | 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 | 100% covered | Every year for those who are at least 45 years old | Stool sample given and processed at home |
| Multi-target Stool DNA Test | 100% covered | Every 3 years for low to moderate risk | Stool sample taken at home and brought to lab |
| Computed Tomography (CT) Colonography | Not covered | Not covered | 15 minutes; no sedation; scanned using CT machine |
Original Medicare consists of Part A hospital insurance and Part B medical insurance. Part B covers preventive services, including colorectal cancer screenings like Cologuard. However, Medicare will only cover Cologuard once every three years for those who meet coverage criteria and have a prescription from a healthcare provider for the test.
Eligibility
The eligibility requirements for Medicare coverage of Cologuard are:
- Age limit: Beneficiaries must be between 50 and 85 years old.
- Asymptomatic status: Individuals should have no signs or symptoms of colorectal disease, such as unexplained weight loss, blood in the stool, lower abdominal pain, or positive fecal immunochemical test.
- Personal history: Beneficiaries should be at average risk for developing colorectal cancer, meaning they have no personal history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease (e.g., Crohn’s disease or ulcerative colitis)
Family history: Beneficiaries should have no family history of colorectal cancers or hereditary colorectal cancer syndromes (e.g., familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer).
How Often Does Medicare Pay for the Cologuard Test?
Medicare Part B covers the Cologuard test once every three years for eligible beneficiaries. This interval aligns with current screening guidelines for average-risk individuals. It’s important to adhere to this schedule, as more frequent testing may not be covered.
How Medicare Advantage Covers Cologuard
Medicare Advantage plans, or Medicare Part C plans, are offered by private insurance companies and replace Original Medicare. These plans are required to cover all services that Original Medicare covers, including preventive services like Cologuard.
It is important to note that Medicare Advantage plans may have different rules, costs, and network restrictions than Original Medicare. Some plans may offer additional benefits beyond Original Medicare. Be sure to check with your specific Medicare Advantage plan to understand how it covers Cologuard and whether any additional requirements or costs apply.
How Much Cologuard Costs with Medicare
For beneficiaries who meet the eligibility criteria, Medicare Part B covers the full cost of the Cologuard test once every three years. This means there is no copayment, coinsurance, or deductible for the test itself.
Other costs associated with maintaining Medicare coverage include:
- Premium: You pay the premium each month to maintain Medicare coverage. Most people are eligible for a no-cost Part A premium, and most pay $185 for Part B in 2025. Medicare Part D and Medicare Advantage plans charge a separate premium.
- Deductible: You pay out of pocket for covered health benefits until you meet your deductible, after which your Medicare plan will begin cost-sharing for your care. However, if you are eligible for Cologuard, you do not have to meet your Part B deductible for coverage.
- Copay and coinsurance: The copay is a flat fee paid per service, such as every time you see your doctor. The coinsurance is the percentage you and your Medicare plan pay for care. Like the deductible, if you are eligible for Cologuard, there should not be a copay or coinsurance for the test.
- Out-of-pocket maximum: Only Part D and Medicare Advantage plans feature out-of-pocket maximums. This is the cap on how much you spend on covered benefits each year before your plan pays 100% of all remaining costs.
However, if the Cologuard test results are positive, a follow-up diagnostic colonoscopy is necessary. Medicare covers diagnostic colonoscopies, you must first meet the Part B deductible ($257 in 2025), after which the colonoscopy will be subject to 20% coinsurance. It’s advisable to compare your healthcare needs with your current coverage to understand the potential costs associated with necessary follow-up procedures.
Putting It All Together
Cologuard offers a convenient, noninvasive option for colorectal cancer screening, and Medicare provides coverage for eligible beneficiaries. Understanding the specific eligibility requirements and coverage details is essential to ensure that you can utilize this preventive service effectively. Regular screening is a vital component of preventive healthcare, aiding in the early detection and treatment of colorectal cancer. Speak with your doctor to determine if Cologuard is appropriate for you.
Sources
- Screening for Colorectal Cancer – Stool DNA Testing. CMS.gov
- Multi-target stool DNA tests. Medicare.gov
- Colonoscopy after Positive FIT Test Cuts Risk of Colorectal Cancer Death. Cancer.gov
- Cologuard. Cologuard.com
- Cancer Stat Facts: Colorectal Cancer. Cancer.gov