Medicare Plan A does not cover Cologuard

Medicare Plan A (Original Medicare hospital insurance) does not pay for Cologuard, a take-home colorectal cancer screening test. Plan A covers inpatient hospital stays, skilled nursing care, and some home health services — not outpatient screening tests done at home.

Cologuard is a stool-based DNA test that screens for colorectal cancer and precancerous polyps. It is ordered by your doctor and mailed to your home. Because it is a screening test performed outside a hospital or doctor's office, Plan A does not cover it. You would need to pay the full cost out of pocket, or look to other coverage options.

If you have Medicare Plan B (Original Medicare medical insurance), the picture is different. Plan B covers colorectal cancer screening tests that meet Medicare's coverage rules, but Cologuard has specific requirements you need to know about.

Key Takeaways

  • Medicare Plan A does not cover any outpatient screening tests, including Cologuard.
  • Medicare Plan B covers Cologuard only if your doctor orders it and you meet age and risk criteria set by Medicare.
  • If you have a Medigap or Medicare Advantage plan, coverage depends on that specific plan's rules, not on Original Medicare rules.
  • The cost of Cologuard without insurance is typically $500 to $700, though your doctor's office may have information about patient information programs.

What Medicare Plan B covers for colorectal screening

If you have Medicare Plan B, you may have coverage for Cologuard under specific conditions. Medicare covers Cologuard as a screening test for people aged 50 to 85 who are at average risk for colorectal cancer and have not had certain other screening tests recently.

Your doctor must order the test, and you must meet Medicare's medical necessity rules. Medicare will not cover Cologuard if you have had a colonoscopy, flexible sigmoidoscopy, or CT colonography within the past 10 years, or a previous Cologuard test within the past 3 years. If you meet these conditions, Plan B typically covers 100% of the cost after you have met your annual deductible.

The key difference from Plan A: Plan B is medical insurance that covers doctor visits and outpatient services. Plan A is hospital insurance only. If you have Original Medicare, you need both Plan A and Plan B for full coverage.

Medicare Advantage and Medigap coverage for Cologuard

If you have a Medicare Advantage plan (Part C), coverage for Cologuard depends on your specific plan. Some Advantage plans cover it the same way Plan B does; others may have different rules, higher out-of-pocket costs, or may not cover it at all. You need to check your plan's formulary or call the plan directly to find out.

Medigap plans (supplemental insurance) do not cover Cologuard itself. Medigap pays for costs that Original Medicare does not cover — such as copayments and coinsurance. If Plan B covers Cologuard, Medigap will not add anything. If Plan B does not cover it, Medigap will not either.

The fastest way to know your coverage: call the customer service number on the back of your insurance card and ask whether Cologuard is covered under your plan.

How to learn about your coverage includes Cologuard

Start by contacting your insurance plan directly. If you have Original Medicare (Plan A and B), call 1-800-MEDICARE. If you have a Medicare Advantage or Medigap plan, call the number on your insurance card.

When you call, have your Medicare number ready and ask: "Does my plan cover Cologuard screening?" If the answer is yes, ask whether your doctor needs to order it in a certain way, whether you need prior authorization, and what your out-of-pocket cost will be.

You can also ask your doctor's office. Many offices know which screening tests their patients' insurance covers and can tell you before you order the test. Some offices also know about manufacturer information programs if you do not have coverage.

What to do if Medicare does not cover Cologuard

If your coverage does not include Cologuard, you have several options. The most common is to pay out of pocket. Cologuard typically costs $500 to $700 without insurance, though some people receive discounts if they pay directly.

Ask your doctor about other screening options that Medicare does cover. Medicare covers colonoscopy, flexible sigmoidoscopy, and CT colonography at no cost to you if your doctor orders them for screening purposes. These are all effective ways to screen for colorectal cancer and may be covered when Cologuard is not.

You can also ask whether the Cologuard manufacturer offers a patient information program. Some companies reduce or waive the cost for people who cannot afford the test. Your doctor's office may have information about this, or you can contact Cologuard directly through their website.

Age and risk requirements for Medicare coverage

Medicare covers colorectal cancer screening for people aged 50 to 85 at average risk. If you are younger than 50 or older than 85, Medicare does not cover screening tests unless you have a personal or family history of colorectal cancer or certain other risk factors.

If you are at higher risk — for example, because you have a family history of colorectal cancer, a personal history of polyps, or inflammatory bowel disease — talk to your doctor about what screening tests are right for you. Your doctor can determine whether you meet Medicare's criteria for coverage and which test is most appropriate.

Frequently Asked Questions

Can I use Cologuard if I have a colonoscopy scheduled?

Medicare will not cover Cologuard if you have had a colonoscopy within the past 10 years. If you are due for screening and your doctor recommends Cologuard, ask whether you should have the colonoscopy instead, since Medicare covers that at no cost to you. Your doctor can help you decide which test makes sense for your situation.

Does my Medigap plan cover Cologuard if Plan B does not?

No. Medigap only covers costs that Original Medicare covers. If Plan B does not cover Cologuard, your Medigap plan will not either. You would need to pay out of pocket or explore other screening options that Plan B does cover.

What if my doctor says I need Cologuard but Medicare says I do not meet the criteria?

If your doctor believes you need screening based on your personal or family history, ask them to document the medical reason. Medicare may cover the test if your doctor can show that you have a condition or risk factor that makes screening medically necessary, even if you do not fit the standard age or risk category.

Can I get Cologuard covered under a Medicare Advantage plan if Original Medicare does not cover it?

Possibly. Some Medicare Advantage plans have different coverage rules than Original Medicare. Call your Advantage plan directly to ask about Cologuard coverage. Even if Original Medicare does not cover it, your specific plan might.

Is there a way to get Cologuard for free or at a reduced cost?

If you cannot afford the full cost, ask your doctor's office about the manufacturer's patient information program. Some people also receive discounts by paying directly rather than through insurance. Your doctor can point you toward resources that may help reduce the cost.