Wellcare Medicare Coverage of Colonoscopy Procedures

In this article...
  • A colonoscopy is a screening test that can help detect abnormalities in the colon, and Wellcare Medicare may help cover some costs of the test. Find out more.

A colonoscopy is a medical procedure in which a physician examines the colon and rectal area for polyps and other abnormalities via a small camera affixed to a flexible tube. The tube is inserted into the rectum, and the camera captures images inside the colon. If any polyps or suspicious areas are detected, the physician may biopsy tissue samples for further examination. Colonoscopies can sometimes help physicians detect colorectal cancer in its early stages, and the procedure is also used when placing stents or removing objects from the colon or rectal area. 

Does Wellcare Medicare Cover Colonoscopy? 

Both Wellcare and Medicare provide coverage for colorectal screenings. Original Medicare provides coverage every 24 months for individuals who are at risk for colon cancer, and Wellcare plans are typically required to cover all procedures and medical services covered by Original Medicare. However, medical costs and plan specifics may vary from state to state, so it's always a good idea for recipients to contact their plans directly to verify coverage details.

For those who aren't considered high-risk, Medicare covers colonoscopy screenings every 120 months or every 48 months following flexible sigmoidoscopy exams of the rectum. If a Medicare recipient's physician accepts Medicare, out-of-pocket costs for colonoscopy screenings are usually zero. However, if a biopsy or tissue removal procedure takes place during the colonoscopy, recipients may be required to pay 20% of Medicare-approved amounts. 

For Original Medicare recipients, specific out-of-pocket costs can vary based on factors such as whether the recipient has supplemental insurance, physician charges and the type of facility in which the screening takes place. 

What Is the Difference Between Wellcare and Medicare?

Wellcare is an HMO with a Medicare contract that offers Medicare Advantage plans. The Wellcare organization is also an approved Medicare Part D sponsor. Medicare is a national health program funded by the government that provides insurance plans to individuals aged 65 or older and people under 65 with disabilities. While Wellcare offers Medicare Advantage plans, it is not managed by the federal government. Wellcare may offer more coverage for certain services and procedures than Original Medicare without additional Medicare supplement plan costs. 

Are Colonoscopy Screenings Considered Preventive Care?

Colonoscopies are generally considered preventive procedures when no polyps or masses are found and the individual undergoing the screening test does not exhibit gastrointestinal symptoms. Insurance companies are usually required to cover the cost of preventive colonoscopies because preventive services are considered essential under the Affordable Care Act (ACA). 

When Are Colonoscopies Not Covered by Insurance?

While preventive colonoscopies are generally covered by insurance, diagnostic colonoscopies may not be fully covered. During a diagnostic colonoscopy, a physician may remove suspicious tissue or colon polyps, or they may check for bleeding, inflammation or signs of gastrointestinal conditions such as ulcerative colitis. Out-of-pocket costs for diagnostic colonoscopies may include standard physician billing, anesthesia costs and pathology lab costs. 

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