Does Health Insurance Cover a Colonoscopy?


WRITTEN BY: Craig Sturgill

UPDATED: AUGUST 24, 2022 | 1 MIN READ

A colonoscopy is a preventative care screening test that helps detect colon cancer. Seeing the signs of cancer early enough makes it easier to prevent or treat cancer. Understanding your health insurance coverage lets you determine if you will be out of pocket for expenses.

What Is a Colonoscopy, and Do You Need One?

Men and women over 45 should be screened every ten years. But, if your family is at high risk of colon cancer, your doctor might recommend you get one sooner.

What’s a colonoscopy?

A colonoscopy examines your colon/large intestine using a thin tube and a camera called an endoscope. If the doctor sees a growth, he will take a sample for biopsy. 

What happens during a colonoscopy?

You are given a sedative to relax. Then, the doctor looks at your colon with an endoscope. You are awake, but you aren’t aware of it. Afterward, you recover in a room while the doctor reviews your results. If a biopsy occurs, you get the results in a few days.

What’s the difference between a screening colonoscopy and a diagnostic one?

A colonoscopy is preventative care and an essential health benefit under the Affordable Care Act. People get preventive colonoscopies to check for polyps, which could be cancerous.

During a diagnostic colonoscopy, the doctor already knows there’s an issue. In this case, the doctor completes the colonoscopy to take a biopsy for a diagnosis.

Who needs to get a colonoscopy?

Any man or woman over 45 can get a colonoscopy and then get one continuing every ten years. You should consider getting one sooner if colon cancer runs in your family. 

Does Health Insurance Cover a Colonoscopy?

The Affordable Care Act (ACA) requires insurance companies to cover certain preventative services such as colonoscopies. But, insurance companies have established strict guidelines for determining what a preventive service is. Those guidelines may exclude people who already have symptoms or have colon cancer in their family history.

Does private health insurance cover colonoscopies?

Coverage for diagnostic colonoscopies varies. Ask your insurer about co-pays, deductibles, limits, exclusions, or other out-of-pocket expenses. 

Does marketplace health insurance cover a colonoscopy?

Yes, the types of insurance plans from the Marketplace cover the costs of colonoscopy. However, you might incur out-of-pocket expenses, such as a bowel prep kit, anesthesia, pathology costs, and a facility fee.

Does Medicare cover a colonoscopy?

Medicare pays the total cost of a preventive colonoscopy as long as a medical provider who accepts Medicare does the procedure. If they find a polyp and perform a biopsy, it’s considered diagnostic rather than preventive, and you could need to pay 20 percent.

Does Medicaid cover a colonoscopy?

States have mandated colonoscopy screening under Medicaid. However, Medicaid might not cover a colorectal cancer screening before age 45 if you don’t have symptoms.

What To Do If Your Insurance Won’t Cover Your Colonoscopy

If your insurance doesn’t cover a colonoscopy, a few options exist. 

Can you get your health insurance to cover a colonoscopy if you’re under 45?

To get a colonoscopy covered before the age of 45 is dependent on your medical history. If you are at high risk of colon cancer due to family history or are exhibiting signs of colon cancer, you are eligible to get it covered.

Advocating for your health is essential to getting your healthcare needs met. If you think you need a colonoscopy, ask your doctor about it during your annual physical exam.

Alternatives to a colonoscopy

A colonoscopy is the best way to determine if you have colon cancer. There are other tests, but they are not as accurate:

  • Stool test: looks only at stool
  • Fecal DNA: looks at cancer cells inside fecal mater
  • Flexible sigmoidoscopy: looks at lower colon
  • CT Colonography: low dose radiation to view a picture of the colon

FAQs

Is anesthesia for a colonoscopy covered by insurance?

Anesthesia is covered fully if your doctor determines that anesthesia is medically needed.

Is a colonoscopy considered preventative?

Yes, because colon cancer can be treated if it is detected soon enough. 

Are colonoscopies free under the Affordable Care Act?

The Affordable Care Act deemed colonoscopies essential health care at no cost to the patient.

Is a colonoscopy considered surgery?

It’s an outpatient surgery. The procedure takes place in a hospital and enables a surgeon to examine the lining of the colon and rectum. 

Can you be awake during a colonoscopy?

Yes, but you’re not aware of the procedure. 

Finding Insurance That Covers Colonoscopies

Finding health insurance covers all your needs, including preventive services such as a colonoscopy. Get a health insurance quote to determine available coverages and the costs involved.