Does Medicare Cover Cologuard?

Does Medicare Cover Cologuard

Colorectal cancer (CRC) is the third leading cause of death for both men and women.

While most frequently diagnosed among those ages 65 to 74, colorectal can also affect those younger than 50, and incidents of colorectal cancer in younger adults are increasing each year. However, according to recent data from the U.S. Preventive Services Task Force (USPSTF), more than 30% of eligible adults are not up-to-date with their screening.

Luckily, Medicare covers several preventive screenings that help detect cancer early, when treatment is most likely to be successful. One of these is Cologuard, an at-home screening test that can help catch colon and rectal cancer.

Read on to learn more about Cologuard Medicare coverage, as well as coverage for other colorectal cancer screening tests, why and how often to get screened, symptoms, and risk factors.

What is Cologuard?

Cologuard is a non-invasive, at-home screening test for adults aged 45 and older who are at average risk for colorectal cancer. This screening detects certain DNA markers and blood in the stool that can indicate the presence of colon cancer or rectal cancer.

Each day, your colon sheds cells that line it. As part of this process, both normal and abnormal cells (from precancer or cancer) are shed. As it passes through your colon, your stool picks up those cells and a Cologuard test can help detect them.

As the name implies, the Cologuard collection kit is used to collect your stool sample, and after following the instructions to submit your sample, it will be sent to a lab. The lab will test the sample and send the test results to your doctor, and your doctor will call you with results and next steps. This may include a follow-up visit or test.

Medicare Cologuard coverage

The Centers for Medicare & Medicaid Services (CMS) determined that Cologuard will be covered by Medicare Part B (medical insurance) once every three years for those who meet all of the following criteria:

  • Ages 50 to 85
  • No signs or symptoms of colorectal disease (including but not limited to gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test)
  • At average risk of developing colorectal cancer

You pay $0 for these tests as long as your provider accepts assignment.

Colorectal cancer screenings covered by Medicare

The American Cancer Society supports policies that give all people access to and coverage of early detection tests for cancer, helping to encourage changes to federal law that allows for this. The Affordable Care Act (ACA) requires both private insurance plans and Medicare to cover the costs of colorectal cancer screening tests with no out-of-pocket costs.

While this doesn’t apply to health plans that were in place before the ACA was passed in 2010, most providers do offer options to help detect cancer early, including Medicare.

Medicare covers several colorectal cancer screening tests depending on your risk and other factors, including:

  • Colonoscopies, which involve using a colonoscope to look inside the colon and rectum.
  • Barium enemas, which is an X-ray exam that can detect changes or abnormalities in your large intestine.
  • Fecal occult blood tests, which find blood in the stool.
  • Flexible sigmoidoscopy screenings, in which your provider inserts a narrow, flexible tube equipped with a light and tiny camera to see inside your rectum and lower colon.

Stool DNA tests, including Cologuard, are also covered.

Do Medicare Advantage plans cover colorectal cancer screenings?

Medicare Advantage plans (Part C) are required to cover at least everything that Original Medicare does. This includes screenings for colorectal cancer. Deductibles, co-payments, and co-insurance do not apply as long as you see an in-network provider and meet Medicare’s eligibility requirements.

Why should I get a colorectal cancer screening?

The purpose of any screening test is to look for a disease when you don’t have symptoms to help detect and treat problems early. This helps keep you healthier longer.

Colorectal cancer almost always develops from these precancerous polyps, or abnormal growths, in the colon or rectum. It’s especially important to get a colorectal cancer screening because these tests can find those polyps early so that they can be removed before they turn into cancer, when treatment is most effective.

How often should I be screened for colorectal cancer?

The USPFTF recommends screenings for colorectal cancer in all adults ages 50 to 75. You may also need to get screened between ages 45 to 49 depending on your risk factors. For those older than 75, the USPSTF suggests providers selectively offer screenings, as evidence indicates the net benefit of screening in this age group is small.

How often to get a screening depends on the type of test you are getting and your provider’s recommendations:

  • The guaiac-based fecal occult blood test (gFOBT) and fecal immunochemical test (FIT) can be done once per year
  • FIT-DNA tests are done once every three years
  • Flexible sigmoidoscopies can be done every five years, or every 10 years with a FIT every year
  • Colonoscopies are done every 10 years (for those who do not have an increased risk of colorectal cancer)
  • CT colonography (virtual colonoscopy) can be done every five years

Your doctor will help you determine which test is right for you and how often you should be tested based on your preferences, any medical conditions, personal or family history, genetic syndromes, and other resources available.

Symptoms of colorectal cancer

Colorectal cancer doesn’t always cause symptoms, and it can take a long time for symptoms to present. This means you could have polyps or colorectal cancer and not know it, so it’s really important to get screened regularly.

If you do have symptoms, they could include:

  • Change in bowel habits
  • Blood in or on your stool
  • Diarrhea, constipation, or feeling that your bowel does not empty all the way
  • Abdominal pain, aches, or cramps that don’t go away
  • Unexplained weight loss

These symptoms aren’t always caused by cancer, but you should talk to your doctor if you’re experiencing anything out of the ordinary.

How to reduce risk of colorectal cancer

While your risk of getting colorectal cancer increases as you get older, other risk factors include having inflammatory bowel disease (such as Chron’s disease or ulcerative colitis), a personal or family history of CRDC or polyps, or a genetic syndrome such as Lynch syndrome or familial adenomatous polyposis (FAP).

There are also some lifestyle factors that can increase your risk such as having a sedentary lifestyle, diet low in fruits, vegetables, and fiber and/or high in fat, obesity, alcohol consumption, and tobacco use.

The good news is there are some ways to reduce your risk:

  • Research is ongoing to determine if changes to your diet can reduce your risk, such as having a diet low in animal fats and high in fruits, vegetables, and whole grains
  • Some medications and supplements may help prevent colorectal cancer, including taking a low-dose aspirin each day
  • Increase physical activity
  • Keep a healthy weight
  • Limit alcohol consumption
  • Avoid tobacco

However, the Centers for Disease Control (CDC) and USPSTF agree the best way to reduce your risk is to get screened routinely beginning at age 45.

Additional Resources

Florida native Eric Ruge lives by one rule: Do the right thing. His goal as a Medicare agent is helping people find the right Medicare coverage for their unique medical needs and budget. He believes everyone deserves the peace of mind they get knowing they made the right decision about their Medicare coverage. When he's not working, Eric enjoys spending time with family and friends, watching Tampa sports, and playing the occasional round of golf.


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