Preventive Colorectal Benefits = Free Screening Colonoscopies for Qualified Patients

On Sept. 23, 2010, under the Affordable Care Act, a preventive services provision made some private insurance patients eligible for free important preventive services – including a free colonoscopy screening. On Jan. 1, 2011, that provision was extended to all Medicare patients.


How it works

Medicare patients who are eligible to have a colonoscopy screening will pay no deductible, co-pay or co-insurance. Private insurers that make changes in their plans will also be required to offer full coverage for screening colonoscopies with no out-of-pocket costs going forward. Patients may still be responsible for other services, such as anesthesia, associated with the procedure.

A colonoscopy that is performed in order to explain symptoms is called a diagnostic colonoscopy, which is not covered under the Affordable Care Act. Patients are usually fully liable for all cost related to a scheduled diagnostic colonoscopy.

A screening colonoscopy is NOT a colonoscopy that is performed to explain the patient’s symptoms (i.e. blood in stools, changes in bowel movements, etc.).


Screening Colonoscopy vs. Diagnostic Colonoscopy

A screening colonoscopy is a procedure performed on a patient of screening age in order to find colon polyps or cancer. General guidelines recommend that the age for screening colonoscopies begin at 50 for people at average risk.

There are some cases where a scheduled screening colonoscopy can become a diagnostic colonoscopy, and in those cases a patient becomes responsible for any out-of-pocket costs related to their deductible, co- insurance or co-pays for standard costs like physician and facility fees.

A screening colonoscopy becomes a diagnostic colonoscopy when a physician removes a polyp or takes a biopsy during the procedure.

Also, even though many physicians recommend patients with a family history of polyps or colon cancer get screened earlier than the recommended age, some private insurance companies consider a family history of colon cancer or colon polyps as a criterion for a diagnostic colonoscopy – NOT a screening colonoscopy.


Private Insurance Patients

A private insurance patient can qualify for a screening colonoscopy if they:

  • Are of the recommended screening age
  • Do NOT have any symptoms
  • Do NOT have personal history of colon polyps or colon cancer


Most private insurance companies DO NOT allow their patients to qualify for a screening colonoscopy with:

  • A family history of colon cancer or colon polyps (Call your insurance to determine benefit.)


Costs: Screening Colonoscopy

  • Private insurance patients must call their insurance to determine their benefit.


Costs: Diagnostic Colonoscopy

  • Private insurance patients must call their insurance to determine potential out-of-pocket costs and circumstances.