The 411 on Free Colonoscopy Screenings

Thanks to a new health care provision, it’s now easier and more affordable than ever for patients to prevent diseases like colon cancer.

Under the Affordable Care Act, changes to Medicare now allow many to be eligible for free preventive services like cholesterol screenings, type 2 diabetes screening and colon cancer screenings. For a full list of free preventive services covered under the Affordable Care Act visit www.healthcare.gov.

Colon cancer screenings are extremely important because colon cancer is the third deadliest form of cancer and more than 80 percent of those cases could be prevented with timely screenings.

But as with many governmental health care provisions, there are details and exceptions patients should understand before scheduling their screening colonoscopy. As patients turn to you for advice, it is important to discuss the differences between screening and diagnostic colonoscopies and also how their insurance may play a role in deciding which procedure they receive.

Screening vs. Diagnostic Colonoscopy

Patients may not realize the difference between a screening and a diagnostic colonoscopy – an important distinction when considering the free screening provision.

The new provision covers screenings ONLY, no matter what type of insurance your patient carries, and what classifies as a screening colonoscopy differs between Medicare and private insurance companies.

Physicians should clarify that a colonoscopy screening is performed on patients with no previous personal history of polyps or colon cancer. A diagnostic colonoscopy, on the other hand, is performed on patients with a previous personal history of polyps or cancer, or to investigate occurring symptoms, such as blood in stools and changes in bowel movement.

If a screening colonoscopy becomes a diagnostic procedure, meaning the physician finds and removes a polyp or conducts a biopsy during the procedure, the patient may be responsible for out-of-pocket costs.  Patients with private insurance also might incur some out-of-pocket costs related to a preventive screening colonoscopy.

Further, some private insurance companies consider family history as a determining factor when labeling the procedure. So, even if your patient exhibits no symptoms or doesn’t have a personal history of the disease, their insurance carrier may classify the procedure as “diagnostic” if there is a family history.

We encourage patients to contact their insurance provider before scheduling a procedure to be aware of potential fees. If your patient needs further guidance through this process, please direct them to our center staff that is trained and ready to help.

Eligibility

As with all insurance providers, Medicare or private, there are some stipulations related to eligibility of a screening. Below is a breakdown of information, but it is always best to advise your patient to contact their insurance provider for accurate information.

Private Insurance: Private insurance patients who enrolled in job-related health plans or individual health insurance policies that were created after March 23, 2010, and began their first new “plan year” or “policy year” on or after Sept. 23, 2010, are eligible to receive free screenings, under the following conditions:

  • Age: Patients must be 50 years or older with no symptoms or personal history of polyps or colon cancer.
  • Family History: Some private insurance plans consider family history to be a qualifier for diagnostic screening. Patients should check with their insurance provider.
  • Heads Up: If the surgery center is out-of-network with a payer, the network is not required to extend preventive benefits to out-of-network providers – or may provide those services for a fee.  Also, if the plan is “grandfathered” in, preventive benefits may not be available.


Unlike Medicare, private insurance patients who have a screening colonoscopy may incur additional costs.

In most cases, there are no out-of-pocket charges for an initial screening, but fees for diagnostic colonoscopies vary by provider.  Also, patients may be responsible for additional services, such as anesthesia.  Patients should always check with the insurance provider before scheduling services.

(Of note, some insurance companies may have had these benefits in place prior to the law and already paid 100 percent for screening.)

Medicare: Preventive services, including screening colonoscopies, are already in place.

  • Age: Patients must be 50 years or older, with no symptoms or personal history of polyps or colon cancer.
  • Family History: Patients with a family history still qualify for a screening colonoscopy.
  • Heads Up: For qualified Medicare patients, there is $0 annual deductible and $0 co-insurance for the initial screening colonoscopy. The patient will have to pay 20 percent co-insurance if the procedure is a diagnostic colonoscopy.

For More Information

  • Click here for a shareable guide to 2011 screening guidelines and recommendations.
  • Quick Finder: To find a local screening center, patients can click here to search by zip code.

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