Does Medicare cover Cologuard?

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Dear Connie,

I’m 70 and haven’t had a colon cancer screening; honestly, a colonoscopy frightens me. I’ve heard of a less invasive option – Cologuard. And I’m wondering, does Medicare cover Cologuard?

It’s time to get screened for colon cancer,
John from Georgetown, Texas

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Dear John,

We’re happy to hear you’re weighing your colon cancer screening options. You’ve come to the right place to ask your question, and we’ll do our best to help.

Colorectal cancer is the third most common cancer in the United States. According to the American Cancer Society, there are 106,590 new cases of colon cancer in 2024. Colon cancer is the second most common cancer among women 70 and older and the fourth most common for men 70 and older.

It’s recommended by the U.S. Preventative Services Task Force that all adults aged 45 to 75 be screened for colorectal cancer. Since you’re 70 and have yet to be screened, we highly recommend it.

Agent tip:

“Original Medicare and Medicare Advantage plans cover the Cologuard test once every 36 months. However, you must meet specific criteria. Cologuard is the only screening stool DNA test covered by Medicare.“

There are cases where you might be at an increased or high risk for colon cancer. Here are six instances where you should consult with your doctor and create a screening plan that’s tailored for you.

You are at increased risk of colon cancer if:

• You have one or more family members who have had colon or rectal cancer.
• You have had polyps removed during a colonoscopy.
• You have had colon or rectal cancer.
• You have had radiation to the abdomen or pelvic area to treat prior cancer.

You are at high risk of colorectal cancer if:

• You have inflammatory bowel disease (Crohn’s disease or ulcerative colitis).
• You have a known or suspected genetic syndrome.

If you or anyone you know has an increased risk of colorectal cancer, they should talk to their doctor about when to begin screening, the screening test that’s right for them, and how often they should be screened.

There are several screening tests that can be used to find polyps or colorectal cancer. Most commonly, there are stool-based tests and visual exams of the colon and rectum. These tests require different screening frequencies. Stool-based tests usually require screening at a higher frequency than visual exams.

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Testing options for colorectal cancer

Stool-based tests

• Highly sensitive fecal immunochemical test (FIT) every year.
• Highly sensitive guaiac-based fecal occult blood test (gFOBT) every year.
• Multi-targeted stool DNA test (mt-sDNA) every three years.

A visual exam of the colon and rectum

• Colonoscopy every ten years.
• CT colonography (virtual colonoscopy) every five years.
• Flexible sigmoidoscopy (FSIG) every five years.

It’s critical that you know that if your test is positive on some screening tests, a colonoscopy is needed to complete the screening process. You should consult your doctor to determine which test is right for you.

Cologuard is a multitarget ​stool DNA test. It is a detection tool used to evaluate fecal matter to determine whether colorectal cancer is present in the sample. It is a non-invasive sample, unlike standard colonoscopy procedures.

Once the fecal sample is collected, a DNA test evaluates whether or not blood and specific DNA mutations are in the sample. The test can also reveal particular markers that note whether or not polyps have formed in the digestive tract.

This test is best for those with an average risk of colorectal cancer and not those with an increased or high risk. Cologuard is also not designed to replace a colonoscopy.

As of October 2014, the Centers for Medicare and Medicaid Services (CMS) determined that Original Medicare Part B would begin covering the Cologuard test once every 36 months. However, you must meet specific criteria.

Cologuard Qualifications

To qualify, you must be between 50 and 85, asymptomatic for colorectal cancer, and at average risk of developing colorectal cancer.

This means you should not have any signs or symptoms of the disease, including but not limited to gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test.

You must also have no personal history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.

Cologuard Cost

Because colon cancer screening is a preventative measure, Original Medicare Part B will cover Cologuard screenings at no cost. All other screening stool DNA tests remain nationally non-covered. You should check with your insurance plan if you want another type of DNA colon cancer screening.

Medicare Advantage plans must provide the same benefits as Original Medicare. So, these plans also cover colon and rectal cancer screenings.

I hope that this helps you answer the question “Does Medicare cover Cologuard?” It’s crucial that you get your preventative care screenings. Curious if Medicare covers a colonoscopy? We’ve also responded to that question: Does Medicare cover colonoscopy?

At Connie Health, we help you throughout your Medicare journey. If you have additional coverage questions, contact a local licensed Connie Health agent at (623) 223-8884 (TTY: 711).

Frequently Asked Questions

Does Medicare pay for Cologuard?

Yes. If you qualify, Original Medicare and Medicare Advantage plans pay for the preventative Cologuard screening once every 36 months. Cologuard is the only DNA colon cancer screening that is covered by Medicare.

To qualify for a Cologuard test, you must meet the following criteria:

• You are aged 50 to 85 years.
• You are asymptomatic for colorectal disease (no signs or symptoms of lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test).
• You are at average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).

How often does Medicare pay for Cologuard test?

Original Medicare Part B and Medicare Advantage cover the Cologuard test once every 36 months.

However, you must meet the following criteria to qualify:

• You are aged 50 to 85 years,
• You are asymptomatic for colorectal disease (no signs or symptoms of lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and
• You are at average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).

 

Is Cologuard covered by Medicare?

Cologuard screenings are covered by Original Medicare Part B at no cost. If you are enrolled in a Medicare Advantage plan, they must provide the same benefits as Original Medicare. So, these plans also cover Cologuard screenings at no cost.

You should check with your insurance plan if you’re interested in another type of DNA colon cancer screening.

Does Medicare cover colonoscopy after Cologuard?

Colonoscopies are usually a preventative procedure. If you’ve had a positive Cologuard test, a colonoscopy afterward is now a diagnostic service. Because of this, you will owe coinsurance with the service.

The coinsurance percentage is changing. Here are the percentages you can expect to pay between 2024 and 2030 and beyond.

• From 2024 to 2026, a 15% coinsurance rate may be due.
• From 2027 to 2029, a 10% coinsurance rate may be due.
• Starting in 2030, there may be no coinsurance.