Wellcare Medicare Coverage of Colonoscopy Procedures

Medicare Advantage (Medicare Part C) plans, including plans offered by Wellcare, cover colonoscopies for qualified plan members.

All Medicare Advantage plans are sold by private insurance companies and are required to cover everything Original Medicare (Medicare Parts A and B) covers. This means Wellcare Medicare Advantage plans cover a colonoscopy as frequently as every 24 months for beneficiaries who are considered high risk for colon cancer.

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 Pay for Colonoscopy? 

Both Wellcare and Original Medicare provide coverage for colorectal screenings.

Original Medicare provides coverage every 24 months for individuals who are at risk for colon cancer, and Wellcare Medicare Advantage plans are required to cover all procedures and medical services covered by Original Medicare.

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. Some Wellcare Medicare Advantage plans may feature deductibles or copays that are different from Original Medicare, and some plans may require you to visit an in-network doctor for your colonoscopy.

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 beneficiary'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.

What Is the Difference Between Wellcare and Medicare?

While Wellcare offers Medicare Advantage plans, the company itself is not managed by the federal government. The Centers for Medicare & Medicaid Services (CMS) enforces guidelines on how insurance companies like Wellcare cover beneficiaries in their Medicare Advantage plans.

Wellcare Medicare Advantage plans may offer more coverage for certain services and procedures than Original Medicare, such as coverage for things like dental, vision, hearing or prescription drugs.

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).

Out-of-pocket costs for diagnostic colonoscopies may include standard physician billing, anesthesia costs and pathology lab costs. 

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