Medicare and Cologuard

Cologuard is a diagnostic tool manufactured by Exact Sciences used for the assessment of colon cancer. If your physician has recommended this test, it would be advisable to check whether it is covered by Medicare or any other insurance policy. Here is the information you need to find out whether Cologuard is covered by Medicare or not.

What is Cologuard?

It is a non-invasive procedure, which means the procedure using Cologuard does not require the insertion of any instrument into the body. It is basically a stool-based DNA test designed to analyze the presence of certain DNA mutations and blood in the patient’s stool sample to detect or rule out the presence of cancerous cells or any precancerous polyp.

The stools contain the cells of DNA that are released continuously during various digestive processes. While there are several other screening options to test the presence of blood in the stools, the Cologuard test is considered superior for the accurate results it provides.

Will Medicare help pay for Cologuard?

Earlier Cologuard was not covered by Medicare and most other insurance policies.

However, a few years back, the Centers for Medicare & Medicaid Services (CMS) made an announcement that Cologuard would be covered by Medicare based on the CMS National Coverage Decision.

This decision has been of great benefit for the patients who are experiencing symptoms such as blood in stools, recurrent loose motions, and drastic weight loss that indicate the risk of colon cancer.

The announcement by CMC also mentioned that the patients who were already enrolled in Medicare would not have to bear the expenses of any co-insurance or co-pays if they obtain the Cologuard kit.

However, it is important to note that patients who have insurance plans other than Medicare such as Medicare Advantage may be responsible for some out-of-pocket expenses related to the Cologuard kit.

Cologuard screening guidelines

There are several agencies, which review the screening tests for colorectal cancer. Currently, the US Multi-Society Task Force on Colorectal Cancer, the Joint Guideline from the American Cancer Society, and the American College of Radiology have recommended DNA tests of stools using Cologuard kit to detect colorectal cancer.

But, the U.S. Preventive Services Task Force guidelines for the screening of colorectal cancer have not been modified to include stool DNA testing.

However, Medicare is not bound by the professional guidelines recommended by these agencies. Hence, it has chosen to cover the Cologuard kit as a testing option based on the evidence provided regarding its efficacy and accuracy of results.

The Affordable Care Act

Regardless of the insurance you are having, the Affordable Care Act mandates the insurance providers to follow the guidelines of the U.S. Preventive Services Task Force for coverage. If the screening test has received an A or B rating by this agency, private insurance companies would cover the cost of the test without charging a co-pay.

But, Medicare is exempted from this mandate and you may need to pay co-pays and co-insurance.