Commercially insured patients:
On January 10, 2022, the Department of Labor put out new guidance related to coverage of preventive services under the Affordable Care Act. For plan or policy years beginning on or after May 31, 2022, health plans are required to cover, without cost sharing, a colonoscopy conducted after a positive stool-based test, like Cologuard1. Many health plans already cover a colonoscopy after a positive stool-based test with no out-of-pocket cost to the patient. Several states have also passed state laws that require some plans in those states to cover colonoscopies after a positive stool-based test at no out-of-pocket cost to the patient.
Medicare and Medicare Advantage:
The Centers for Medicare & Medicaid Services (CMS) is in the process of updating its policy around colonoscopy after a positive stool-based screening test. Until CMS finalizes its new policy (expected January 2023), people with Medicare Part B may receive a bill for this type of colonoscopy that includes co-insurance (typically 20%) and the deductible. People with Medicare Advantage may receive a bill for a colonoscopy following a positive stool-based screening test that includes co-insurance (in varying amounts, depending on the plan) and a deductible2.
If you receive a bill for a colonoscopy, please call our Customer Care Center 24/7 at 1-844-870-8870 or visit our appeals page to create a customized letter to send to your insurance company.
1. See FAQS ABOUT AFFORDABLE CARE ACT IMPLEMENTATION PART 51, FAMILIES FIRST CORONAVIRUS RESPONSE ACT AND CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURITY ACT IMPLEMENTATION at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs#Affordable_Care_Act.
2. See Medicare Claims Processing Manual, Chapter 18 - Preventive and Screening Services https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c18pdf.pdf