Most insured
people pay $0*
Cologuard® is covered by Medicare and most major insurers
Nationwide, more than 94% of Cologuard patients have no out-of-pocket cost for screening.*
*Exact Sciences estimate based on historical patient billing. Rate of coverage varies by state and region. Exceptions for coverage may apply; only your patients' insurers can confirm how Cologuard would be covered.
Special Topic: Coverage for Colonoscopy After a Positive Cologuard Result
A patient with a positive Cologuard result should receive a colonoscopy for the screening to be completed. This helps you understand what this positive result means for you. Discuss your options with your healthcare provider.
Millions of patients have access to colonoscopy after a positive Cologuard test with no out-of-pocket cost. The federal government created patient financial protections that expand the number of plans covering these colonoscopies without cost. Read below for info on commercial health plans, Medicare and Medicare Advantage, and how they may cover a colonoscopy after a positive Cologuard test. Read more
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Read moreCommercially insured patients:What happened? On January 10, 2022, the federal government issued new guidance related to coverage of preventive services under the Affordable Care Act.What does this mean for patients?
- For plan or policy years beginning on or after May 31, 2022, health plans must cover, without cost sharing, a colonoscopy conducted after a positive stool-based test, including Cologuard.1
- Many health plans already waived the cost after a positive stool-based test. Several states also passed laws that require many plans in those states to cover colonoscopies after a positive stool-based test at no out-of-pocket cost to the patient.
- The federal update makes these protections even more available.
Medicare and Medicare Advantage:What happened? The Centers for Medicare & Medicaid Services (CMS) finalized a new policy, effective January 1, 2023.What does this mean for patients?- The new policy removes Medicare cost-sharing requirements under Part B for colonoscopy after a patient has a positive stool-based test prior to the procedure.
- Some components of a colonoscopy (such as the removal of tissue) can result in the patient having coinsurance. This cost would apply regardless of whether the patient had a positive stool-based test.
- CMS lowered this cost sharing to 15%. CMS will gradually reduce this coinsurance until it’s completely removed by January 1, 2030.
Your insurer is the best source of info on your plan.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.References: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.
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Read more
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.
References:
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