Cologuard is covered by most insurance plans at no cost to you. The Affordable Care Act requires both private insurers and Medicare to cover colorectal cancer screening tests recommended by the U.S. Preventive Services Task Force, with no copays or deductibles. Since Cologuard falls under that umbrella, the vast majority of insured adults between 45 and 75 can get the test without paying anything out of pocket.
Medicare Coverage Details
Medicare has covered Cologuard since October 2014. Starting January 1, 2023, the minimum age dropped from 50 to 45, aligning with updated screening guidelines. Medicare covers the test once every three years for beneficiaries aged 45 to 85 who meet all of the following criteria: they have no signs or symptoms of colorectal disease (such as blood in stool or lower gastrointestinal pain), and they are at average risk for colorectal cancer.
Average risk, in Medicare’s definition, means no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease (including Crohn’s disease and ulcerative colitis), and no family history of colorectal cancer or hereditary cancer syndromes. If you fall into a higher-risk category, Medicare won’t cover Cologuard because colonoscopy is the recommended screening method for those individuals.
Private Insurance Under the ACA
The ACA requires private health plans to cover all USPSTF-recommended colorectal cancer screening tests with zero cost-sharing. That means no copay, no coinsurance, and no deductible applied to the test. The USPSTF recommends screening for all adults aged 45 to 75, and Cologuard is among the accepted screening options. Between ages 76 and 85, screening becomes an individual decision made with your doctor, and coverage can vary by plan.
One important caveat: if the provider ordering or processing the test is out of network, you could still face out-of-pocket charges. Before ordering the test, confirm that your provider is in-network to avoid surprise bills.
Medicaid Coverage
Medicaid coverage for Cologuard varies by state. Some states have explicitly approved it. North Carolina, for example, began covering Cologuard in July 2018 for beneficiaries aged 50 to 85 at average risk, once every three years. Other states may follow similar criteria, but because Medicaid is administered at the state level, the age range, frequency, and eligibility rules differ depending on where you live. Contact your state Medicaid program or check their provider manual to confirm coverage before ordering the test.
Who Doesn’t Qualify for Coverage
Insurance plans consistently exclude Cologuard coverage for people who aren’t considered average risk. You’ll typically be denied coverage if you have:
- A personal history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease
- A family history of colorectal cancer, adenomatous polyps, or hereditary syndromes like Lynch syndrome or familial adenomatous polyposis
- Current symptoms of colorectal disease, including blood in stool, a recent positive stool test, or lower GI pain
If any of these apply to you, your doctor will likely recommend a colonoscopy instead, which is the preferred screening tool for higher-risk patients. That colonoscopy would typically be covered as a diagnostic or screening procedure under its own set of insurance rules.
What Happens If Cologuard Comes Back Positive
A positive Cologuard result requires a follow-up colonoscopy, and this is where many people worry about getting hit with a large bill. The good news: as of January 1, 2023, Medicare treats the follow-up colonoscopy after a positive stool-based test as part of the complete screening process. That means no deductible and no coinsurance for that colonoscopy. CMS considers both the initial stool test and the follow-up colonoscopy to be preventive screening services.
For private insurance, the ACA similarly treats polyp removal during a screening colonoscopy as an integral part of the screening itself, so patients should not face additional charges for it. Before 2023, many patients received surprise bills when their “screening” colonoscopy was reclassified as “diagnostic” after a positive Cologuard. The updated rules were designed to close that loophole.
The Three-Year Frequency Rule
Both Medicare and most private insurers cover Cologuard once every three years. If you try to order it sooner, your insurance will likely deny the claim, and you’d be responsible for the full cost, which runs around $600 to $700 without coverage. Keep track of when you last completed the test so you know when you’re eligible again. If you had another type of colorectal screening recently, such as a colonoscopy within the past 10 years or a fecal immunochemical test within the past year, that may also affect your eligibility for a covered Cologuard test.