Cancer Screenings & Medicare Coverage

Cancer screenings can be lifesaving procedures when they catch cancer early and allow patients to undergo treatment before the disease is able to progress. For that reason, Medicare and other insurance plans cover many cancer screenings at 100% of the Medicare-approved cost as a form of preventative care. However, coverage is not the same across the board, and coverage varies based on the type of screening and your particular Medicare plan. In this article, we’ll focus on a few specific types of cancer screenings and break down how Medicare coverage may apply to each of these medicare preventive services.

No matter the type of screening or the specific type of Medicare coverage you have, it’s important to schedule any appointments with a participating in-network provider. That will guarantee you receive the maximum amount of coverage and avoid unexpected out-of-pocket costs. Being prepared ahead of time and understanding how coverage applies to your unique situation is critical in avoiding surprise pitfalls.
As a starting point, it’s helpful to understand the difference between screening tests and diagnostic tests. Screening tests are designed to determine whether a patient is at risk for a certain condition. They are often performed for all people in certain demographics whether or not they have any symptoms of the condition. Most screenings are covered at 100%. Diagnostic tests, or diagnostic screenings, on the other hand, are more extensive tests performed only where there is reason to believe a person may have a condition. These tests can often determine definitively whether a certain condition is present and can be used as a basis to start treatment. These diagnostic tests are not always covered at 100% by Medicare or other insurance.

Just because your screenings is covered at 100% doesn’t mean you’ll get away from your visit without a bill. Some clinics and hospitals charge a facility fee regardless of the type of treatment you receive. That facility fee is not covered by Medicare. If you meet with your doctor for a general visit in addition to your screening, that visit may cost you as well. If your doctor determines either based on your screening or other conversation that you would benefit from treatment, you will likely be charged for that treatment as well. When you get a bill, make sure you examine it carefully to make sure you understand what you’re being charged and why.

Mammogram Screening

Screening mammograms are recommended for all women over the age of 40, and Medicare will fully cover one screening every 12 months for women over that age. Based on that screening or other factors, your provider may choose to perform a more extensive diagnostic mammogram. That mammogram takes longer as the provider takes additional images and performs additional analysis. Since these mammograms are not considered purely preventative, they are not covered at 100%, but rather at 80% of the approved Medicare rate. You would pay 20% coinsurance after meeting your deductible.

It’s possible that you could go to the doctor planning on only a screening mammogram, but that based on that mammogram, the provider chooses to do a more extensive diagnostic mammogram. If that occurs, don’t be surprised to get a bill for the additional screening.

It’s important to note that mammogram coverage may differ for women who have had breast cancer in the past. These women may be entitled to higher amounts of coverage.

Cervical and Vaginal Cancer Screening

Pap smears are a common form of screening for women and can be used to identify a wide array of health concerns. Among those are cervical and vaginal cancer. Every woman can have a Pap smear covered at 100% every two years. Women with the following characteristics can have a Pap smear covered every year.

  • You are considered to be childbearing age and have had an abnormal Pap smear in the last three years
  • You were sexually active before you were 16
  • You have had five or more sexual partners in your lifetime
  • You have had a sexually transmitted infection (STI) or sexually transmitted disease (STD)
  • Your mother took diethylstilbestrol (DES) during pregnancy
  • You have received three or fewer negative Pap smears
  • You have not had a Pap smear within the past seven years

Pap smears are an important piece of preventative care for women, and especially for women who have a higher than average risk of cervical cancer, vaginal cancer, or other conditions. This preventative screening may lead to additional treatment that is not covered at 100%.

Colorectal Screening

There are several different screenings for colorectal cancer, and Medicare treats each differently.

  • Fecal occult blood test. It is covered at 100% for those over 50 years old, once every 12 months.
  • Flexible sigmoidoscopy is covered at 100% for those over 50 years old. The screening is covered once every four years for anyone considered high risk, or every ten years if you are not high risk, but only after a colonoscopy has been performed.
  • Colonoscopies are covered at 100% once every two years if you are high risk, or once every ten years if you are not at high risk. A colonoscopy will not be covered within two years of a flexible sigmoidoscopy. Note that there are no age limits for a colonoscopy.
  • Barium enema. For those enrolled in Medicare Part B, covered at 80% for those over 50 years old. The screening is covered once every two years if you are high risk, or once every four years if you are not high risk. A barium enema will not be covered within two years of a flexible sigmoidoscopy.
  • Coverage may differ for Medicare Advantage Plan enrollees.

For colorectal cancer, you are considered high risk if you have a family history of colorectal, have had this type of cancer yourself, had colorectal polyps, or have had inflammatory bowel disease.

Treatment performed as a result of the screening may not be covered at 100%, so you may receive a bill for treatment provided after the preventative screening.

Prostate Cancer Screening

Men over the age of 50 are eligible for one prostate screening per year. This might be a digital rectal exam (DRE) or a prostate-specific antigen (PSA) test. Either of these tests will be covered at 100% regardless of the type of Medicare coverage you have.

If additional diagnostics are needed as a result of your risk factors or based on findings in the screening, Medicare will pay 80% of the Medicare-approved amount. Costs may vary for those with a Medicare Advantage Plan.

Lung Cancer Screening

All forms of Medicare cover lung screening at 100% as long as you meet the following qualifications.

  • You are 55 to 77 years old
  • You smoke currently, or have quit smoking within the last 15 years
  • You smoke, or have smoked in the past, an average of one pack of cigarettes a day for a minimum of 30 years
  • You have no symptoms of lung cancer
  • The screening takes place at an in-network facility.

If you meet these criteria, you are entitled to a screening once a year. This screening will be low dose computed tomography, or LCDT. Prior to the first screening, you’ll need to visit your primary care provider and discuss whether the benefits of the screening outweigh the risks. You won’t be required to repeat that consultation before subsequent LCDT scans.

The LCDT scan involves laying on a table while a low dose X-ray machine scans your test. This is a non-invasive test that will be over in a few minutes. Just keep in mind that there can sometimes be risks in too much exposure to even small doses of radiation.

It’s always a good idea to abide by your doctor’s recommendations for screenings, and to stay up to date with screenings based on your age and risk factors. Preventative care saves lives, and often won’t cost you a thing.

Annual Wellness Visit

In addition to regular cancer screenings, make sure you’re keeping up with your Annual Wellness Visits. Everyone on Medicare is entitled to one visit per year covered at 100%. At this visit, your doctor will examine you, ask you questions about your health and lifestyle, and listen to any concerns you have about your health. The main purpose of this visit is to catch any health issues early when they are most easily addressed.

Your doctor can also offer advice on maintaining a healthy lifestyle, make sure you are up to date on all your vaccinations, and recommend any screenings that you should prioritize based on your risk factors.

The moral of the story is that it’s important to prioritize screenings and other preventative care. Early diagnosis and treatment can indeed be life and death in some cases, as outcomes are much better for cancer patients whose condition is caught early. Early treatment also often means lower cost and less disruption to your everyday life. When you understand the screenings options available to you based on your demographics and coverage, you can stay on top of your health and take the initiative on your health.