Medicare Part A does not cover Cologuard
Medicare Part A covers hospital stays, skilled nursing care, and hospice — not outpatient screening tests. Cologuard is a mail-in stool test you do at home to screen for colorectal cancer, so it falls outside Part A's scope entirely.
The test may be covered under Medicare Part B instead, which pays for doctor visits and certain preventive screenings. Whether Part B covers your Cologuard test depends on your age, your doctor's recommendation, and whether you meet Medicare's specific coverage rules for this particular test.
If you have a Medigap or Medicare Advantage plan, your coverage may differ from Original Medicare. The best first step is to contact your plan directly or call Medicare at 1-800-MEDICARE to find out what your specific coverage is before you order the test.
Key Takeaways
- Medicare Part A does not cover Cologuard because it is an outpatient screening test, not a hospital or facility service.
- Medicare Part B may cover Cologuard if your doctor orders it and you meet age and risk criteria, though you may owe a copay or coinsurance.
- Medicare Advantage and Medigap plans have their own coverage rules for Cologuard, which may be more or less generous than Original Medicare.
- You should contact your plan or Medicare before ordering Cologuard to confirm coverage and avoid unexpected costs.
- If Medicare does not cover the test, Cologuard offers a cash price, and some community health centers may offer colorectal screening at lower cost.
What Medicare Part B covers for colorectal screening
Medicare Part B covers colorectal cancer screening for adults age 50 and older as a preventive service with no copay or deductible — but only certain screening methods may have access to. The covered methods are colonoscopy, flexible sigmoidoscopy, and high-sensitivity fecal occult blood test (FOBT). Cologuard is a different type of stool test called a multitarget stool DNA test, and Medicare's coverage rules for it are narrower.
For Cologuard specifically, Medicare Part B covers it once every three years if your doctor orders it and you are age 50 or older with average colorectal cancer risk. If you have a higher risk — for example, a family history of colorectal cancer or a personal history of polyps — your doctor may order it more frequently, and Medicare may cover it, but you should confirm this with your plan before the test is ordered.
If you have already had a colonoscopy within the past 10 years with no polyps found, Medicare may not cover Cologuard during that same period. The test is meant to be an alternative screening method, not a supplement to colonoscopy in low-risk patients.
How to learn about your plan covers Cologuard
Call the customer service number on the back of your Medicare card. Have your card in front of you. Tell them you want to know whether Cologuard is covered under your plan, and ask whether your doctor's order is required before you order the test.
If you have a Medicare Advantage plan, call your plan's customer service line instead of Medicare directly — your plan makes its own coverage decisions. Ask the same questions: Is Cologuard covered? Do I need my doctor to order it first? What will I owe out of pocket?
If you have a Medigap plan, you have Original Medicare plus supplemental coverage. Call both Medicare (1-800-MEDICARE) and your Medigap insurer to understand how the coverage layers work together and what your total out-of-pocket cost will be.
What happens if Medicare does not cover Cologuard
Cologuard costs between $500 and $700 if you pay out of pocket. The company sometimes offers discounts or payment plans on its website, so check there before paying full price. Some people also ask their doctor whether a traditional FOBT (fecal occult blood test) might be covered instead — it is less expensive and is covered by Medicare Part B for all adults age 50 and older.
If cost is a barrier, ask your doctor about colonoscopy screening at a hospital or outpatient center. Medicare Part B covers colonoscopy with no copay if it is done for screening purposes (not diagnosis) and you have not had one in the past 10 years. If polyps are found and removed during the procedure, you may owe a copay for the removal, but the screening itself is free.
Community health centers and federally may have access to health centers (FQHCs) sometimes offer colorectal screening at reduced cost based on income. You can find a center near you by searching the HRSA Find a Health Center tool on the HRSA website.
Medicare Advantage plans and Cologuard coverage
Medicare Advantage plans (Part C) must cover at least the same preventive services as Original Medicare, but many plans cover more. Some Medicare Advantage plans cover Cologuard with no copay, while others may require a copay or may not cover it at all. Coverage varies by plan and by year, so you cannot assume your plan covers it just because another plan does.
The best way to know is to call your plan's customer service number before you order the test. Ask whether Cologuard is on your plan's formulary or covered services list, whether your doctor needs to order it, and what your copay or coinsurance will be. Write down the name of the person you spoke with and the date, in case you need to reference the conversation later.
If your plan does not cover Cologuard but covers colonoscopy, ask your doctor whether colonoscopy is the right choice for you. It is more invasive than a stool test, but it allows your doctor to remove polyps during the same visit, which reduces your cancer risk more effectively.
What to ask your doctor about Cologuard
Before you order Cologuard, talk to your doctor about whether it is the right screening test for you. Ask: Do you recommend Cologuard for my risk level? How often should I be screened? Will you submit the order to my insurance, or do I need to order it myself? What should I do if the test comes back abnormal?
If your doctor recommends Cologuard, ask them to submit the order to your insurance company or to Cologuard directly so that the company can check your coverage before you pay. Some doctors' offices do this automatically; others require you to ask. If you order the test yourself without checking coverage first, you may end up paying out of pocket even if your plan would have covered it.
If your doctor recommends a different screening method — such as colonoscopy or FOBT — ask why they think it is better for you than Cologuard. Understanding the reasoning helps you make an informed choice and also helps you explain the recommendation to your insurance company if there is a coverage question.
When to contact Medicare or your plan about coverage
Contact Medicare or your plan as soon as your doctor recommends Cologuard, before you order the test. Do not wait until the test arrives or until you receive a bill. Confirming coverage ahead of time protects you from unexpected costs and gives your doctor's office time to work with your insurance company if there are any questions.
If your plan denies coverage for Cologuard, ask your doctor to submit an appeal or a letter of medical necessity explaining why the test is appropriate for you. Some plans will reconsider a denial if your doctor provides additional clinical information. Your doctor's office usually handles this process, but you can also contact your plan's appeals department directly if you want to follow up.
If you believe your plan made an error in denying coverage, you have the right to file a formal appeal. Your plan must tell you how to do this in the denial letter. You can also contact your State Health Insurance information Program (SHIP) for free help understanding your appeal rights.
Frequently Asked Questions
Can I order Cologuard without a doctor's order?
Yes, you can order Cologuard directly from the company without a doctor's order and pay out of pocket. However, if you want Medicare or your insurance plan to cover it, your doctor must order it. Even if you order it yourself, ask your doctor to submit an order to your insurance company so the company can determine coverage before you pay.
Will Medicare cover Cologuard if I have never had a colonoscopy?
Yes, Medicare Part B covers Cologuard once every three years for adults age 50 and older with average risk, regardless of whether you have had a colonoscopy before. If you have higher risk factors, your doctor may order it more frequently, but confirm coverage with your plan first.
What if my doctor says I need Cologuard more than once every three years?
If your doctor believes you need more frequent screening due to family history or other risk factors, they can submit a request for coverage exception to your insurance plan. This is called an appeal or prior authorization request. Your doctor's office usually handles this, but it may take a few weeks for your plan to respond.
Does Medigap cover Cologuard if Medicare Part B does not?
Medigap plans pay for services that Original Medicare covers, not services that Medicare denies. If Medicare Part B does not cover Cologuard for you, your Medigap plan will not cover it either. However, if Medicare Part B does cover it and you owe a copay or coinsurance, some Medigap plans will pay that cost.
What should I do if I already paid for Cologuard out of pocket?
Contact Cologuard's customer service and ask whether they can submit a claim to your insurance company retroactively. Some companies will do this if you provide proof of your insurance coverage. If they cannot, ask your insurance company whether you can file a claim yourself for reimbursement, though coverage is not may provide.