Utah · Medicare · Colonoscopy, stool and blood tests, and the polyp rule
Does Medicare Cover Colonoscopy in Utah? (2026 Costs)
Yes. Medicare Part B covers a screening colonoscopy at no cost, with no minimum age, and it also pays in full for the stool tests, the new blood test and, since 2025, a CT colonography. The one thing that can cost a Utah patient money is the thing the test is for: if the doctor finds and removes a polyp, you pay 15% in 2026, 10% from 2027 and nothing from 2030. Here is every covered test and how often, what a colonoscopy actually cost Utahns in CMS's own claims files, how Utah's screening and cancer rates compare with the nation county by county, which Utah gastroenterologists take Medicare, and how a Medigap policy or a Medicare Advantage plan changes the bill.
The bottom line
- Medicare covers colorectal cancer screening at $0. A screening colonoscopy every 10 years (every 2 years at high risk), a stool test for blood every year, a multi-target stool DNA test or a blood-based test every 3 years for people 45 to 85, a CT colonography every 5 years and a flexible sigmoidoscopy every 4 years are all Part B preventive services with no deductible and nothing to pay if the provider accepts assignment. A positive stool or blood test makes the follow-up colonoscopy a screening too.
- The polyp rule is the only cost. If a polyp or tissue is removed during a screening colonoscopy, you pay 15% of the Medicare-approved amount to the doctor and 15% to the facility in 2026, no deductible. That is about $166 in a surgery center and $251 in a hospital outpatient department at 2024 Utah averages and January 2026 facility rates, before the pathology bill. The share drops to 10% in 2027 and 0% in 2030. Medigap Plans G and N pay it.
- Utahns on Medicare screen at or above the national rate: 3,957 Utahns in Original Medicare had a colonoscopy billed as a screening in 2024, 2.16% of everyone with Part B in Original Medicare against 1.80% nationally, and at least 10,289, one in 18, had a colonoscopy of some kind. Among all adults 45 to 75, though, the CDC puts Utah at 63.1% up to date against 66.3% nationally, with 25 of 29 counties below the national figure.
- Utah has the lowest colorectal cancer rate in the country, 30.4 new cases per 100,000 a year against 36.9, and 116.6 against 152.7 among people 65 and older. But 60.3% of Utah cases are still found at a late stage, the same as the nation, which is exactly what screening exists to change.
- 117 of Utah's 121 Medicare-enrolled gastroenterologists accept assignment (97%), so the $0 is real for almost everyone in Original Medicare. In Medicare Advantage the test is covered too, but through the plan's network and, in most HMOs, a referral.
Colorectal cancer screening is the clearest case in Medicare of a test that pays for itself, and the program treats it that way. Medicare.gov's colonoscopy page says Part B “covers screening colonoscopies,” that “there's no minimum age requirement to get a screening,” and that “you pay nothing if your provider accepts assignment.” The same is true of the stool tests, the blood test added to the list in 2021 and the CT colonography added in 2025. The complication, and the reason this article exists, is a single sentence on that same page: “If your health care provider finds and removes a polyp or other tissue during the colonoscopy, you pay 15% of the Medicare-approved amount for your provider's services,” and in a hospital outpatient department or surgery center “you also pay the facility a 15% coinsurance.” Finding a polyp is the point of the test, and in Utah in 2024 it happened often: 6,846 Utahns in Original Medicare had a polyp snared during a colonoscopy, more than had a colonoscopy billed purely as a screening. This article puts Utah numbers on each piece, from CMS's claims files, the CDC's county survey and the national cancer registry, so you know what to expect before the prep.
Which colorectal cancer screening tests does Medicare cover, and how often?
Six tests, each with its own schedule, and Medicare pays all six in full as preventive services. The rules below are quoted from Medicare.gov's coverage pages and CMS's National Coverage Determination 210.3 as of October 2026. “High risk” in Medicare's definition means a personal history of colorectal cancer, adenomatous polyps or inflammatory bowel disease (Crohn's disease or ulcerative colitis), or a family history of colorectal cancer or adenomatous polyps, including the inherited syndromes; “average risk” means none of those and no symptoms.
| Test | Who | How often Medicare covers it | What you pay (provider accepts assignment) |
|---|---|---|---|
| Screening colonoscopy | Anyone with Part B; no minimum age | Every 120 months at average risk, or 48 months after a flexible sigmoidoscopy; every 24 months at high risk; also as the follow-up to a positive stool or blood test, with no frequency limit | $0; 15% to the doctor and 15% to the facility if a polyp or tissue is removed (no deductible) |
| Stool test for blood (guaiac FOBT or immunochemical FIT) | 45 and older, with a referral | Every 12 months | $0 |
| Multi-target stool DNA test (Cologuard) | 45 to 85, no symptoms, average risk | Every 3 years | $0 |
| Blood-based biomarker test | 45 to 85, no symptoms, average risk; test must be FDA-authorized and meet CMS's accuracy thresholds | Every 3 years | $0 |
| CT colonography (“virtual colonoscopy”), covered since Jan. 1, 2025 | 45 and older, ordered by your doctor | Every 60 months at average risk, or 48 months after a sigmoidoscopy or colonoscopy; every 24 months at high risk | $0 |
| Flexible sigmoidoscopy | 45 and older | Every 48 months; 120 months after a screening colonoscopy if not high risk | $0; 15% if tissue is removed |
Sources: Medicare.gov, Colonoscopies (screening); Fecal occult blood tests; Multi-target stool DNA tests; Blood-based biomarker tests for colorectal cancer screening; Computed tomography (CT) colonography (screening); Flexible sigmoidoscopies — medicare.gov; CMS, NCD 210.3 Colorectal Cancer Screening Tests — cms.gov; CMS MLN Matters MM14031 (CY 2025 changes: CT colonography added, barium enema removed, blood-based tests added to the “complete screening” continuum) — cms.gov (PDF).
Three things on that table matter more than they look. First, the “complete screening” rule: CMS's 2025 physician fee schedule rule says that a positive stool-based or blood-based test “will lead to a follow-on screening colonoscopy (with no beneficiary cost-sharing),” and that the usual frequency limits “don't apply to the follow-on screening colonoscopy.” Before 2023 that colonoscopy was billed as diagnostic, at 20% plus the deductible, which was a real deterrent to taking the stool test in the first place. Second, the barium enema, an older X-ray test, was dropped from the list on January 1, 2025 because, in CMS's words, it “is rarely used in Medicare and is no longer recommended.” Third, the two three-year tests have an upper age of 85 and an average-risk requirement; a colonoscopy has neither. Medicare's rules are coverage rules, not medical advice: Medicare.gov links to the U.S. Preventive Services Task Force, which recommends screening adults 45 to 75 and selective screening at 76 to 85, and whether to keep screening past 75 is a conversation for your yearly Wellness visit, where the doctor is supposed to review exactly this schedule with you.
What do you pay for a colonoscopy with Medicare in 2026?
It depends on three things: why the colonoscopy was ordered, whether anything was removed, and which building you had it in. A colonoscopy ordered as a screening, with nothing found, is $0 for the doctor, the facility and the anesthesia. CMS's claims file confirms this in an unusual way: for every Utah screening colonoscopy code and for the anesthesia code that goes with it, the average amount Medicare paid in 2024 equals the average amount it approved, to the penny, meaning the patient's share across thousands of Utah claims was zero. Once a polyp or tissue is removed, the doctor bills a different code with a modifier that tells Medicare the test began as a screening, and the reduced coinsurance applies.
Sources: CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024, Utah facility rows for G0121, G0105, 45385, 00812 and 00811 (average approved and paid amounts); CMS, January 2026 ASC Addenda, Addendum AA (ASC rates) and Addendum FF (OPPS rates for APC 5311 and 5312) — cms.gov; Medicare.gov, Colonoscopies (screening). National rates before geographic adjustment; the pathology laboratory's fee for examining removed tissue is a separate claim and is not included.
The 15% is temporary. Section 122 of the Consolidated Appropriations Act of 2021 told Medicare to phase out the coinsurance that used to apply when a screening colonoscopy “became” a therapeutic one, and CMS's instruction to its contractors lays out the schedule: “For dates of service in CYs 2023–2026, coinsurance is 15%; 2027–2029, coinsurance is 10%; starting 2030, no coinsurance.” The Part B deductible is waived throughout. The table below applies that schedule to the same Utah colonoscopy. One caution the instruction makes clear: the reduced coinsurance applies to procedure codes in the surgical range, the anesthesia code and the sedation code billed with the screening modifier. The pathology laboratory that examines the polyp bills a laboratory code, which the instruction does not list, so expect ordinary Part B cost-sharing on that bill unless a Medigap policy pays it. Ask the endoscopy center which lab it uses and whether it accepts assignment.
| Screening colonoscopy, one polyp removed | Doctor ($332.62 approved) | Facility | Anesthesia ($117.22 approved) | Your total (no Medigap) |
|---|---|---|---|---|
| 2026, surgery center ($656.75 facility rate), 15% | $49.89 | $98.51 | $17.58 | $165.99 |
| 2026, hospital outpatient department ($1,222.44 facility rate), 15% | $49.89 | $183.37 | $17.58 | $250.84 |
| 2027–2029, surgery center, 10% | $33.26 | $65.68 | $11.72 | $110.66 |
| 2027–2029, hospital outpatient department, 10% | $33.26 | $122.24 | $11.72 | $167.23 |
| 2030 and after, any setting, 0% | $0.00 | $0.00 | $0.00 | $0.00 |
| Screening, nothing removed, any year, any setting | $0.00 | $0.00 | $0.00 | $0.00 |
Illustrative, at 2024 Utah average approved amounts for the doctor (45385, facility setting) and anesthesia (00811) and CMS's national January 2026 facility rates, which are held constant across the years for comparison; actual 2027 and 2030 rates will differ. Medicare paid 82% of the approved amount on Utah 45385 claims in 2024, consistent with a mix of screening-origin (15%) and diagnostic (20%) patients. Sources: CMS MLN Matters MM12656, “Colorectal Cancer Screening Tests: Changes to Coinsurance for Related Procedures” — cms.gov (PDF); CMS, January 2026 ASC Addenda AA and FF; CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024.
Where you have it matters less than for most procedures, because the facility fee is small in both settings, but a hospital outpatient department still costs an Original Medicare patient about $84.85 more than a surgery center in 2026 when a polyp is found, and nothing more when it is not. The one setting choice that matters more is sedation. Most Utah colonoscopies now use an anesthesia professional, which is why the anesthesia codes in CMS's file (10,289 Utah patients in 2024) outnumber the colonoscopy codes themselves; the anesthesia fee follows the same 15% rule when the colonoscopy began as a screening and is $0 when nothing is removed. If a doctor who does not accept assignment does the procedure, add up to 15% of the approved amount as an excess charge; as the clinician table below shows, that applies to 4 of Utah's 121 gastroenterologists.
How many Utahns on Medicare get screened, and how does Utah compare?
CMS publishes every Original Medicare claim by billing code and by the state of the clinician, which lets us count Utah colonoscopies and stool tests in 2024 and compare them with the nation on the same denominator: people with Part B in Original Medicare, 183,494 Utahns and 27,982,142 Americans that year. Two cautions apply to every figure below. The files count Original Medicare only, so none of the 269,226 Utahns in Medicare Advantage in June 2026 (54.9% of the state's 490,235 beneficiaries) is in them. And the multi-target stool DNA test and the blood test are billed by the laboratory that runs them, which is in another state, so Utah patients who took those tests appear in that state's rows, not Utah's; nationally 624,969 people in Original Medicare had the stool DNA test in 2024 (average approved amount $498.54) and 3,543 had the blood test ($901.60), from 14 and 1 laboratories respectively.
| Service (billing code) | Utah beneficiaries, 2024 | Utah clinicians billing | Avg. Medicare-approved amount, Utah | Share of Utah Part B Original Medicare | National share |
|---|---|---|---|---|---|
| Screening colonoscopy, not high risk (G0121) | 2,113 | 157 | $250.29 | 1.15% | 0.78% |
| Screening colonoscopy, high risk (G0105) | 1,844 | 141 | $260.80 | 1.00% | 1.01% |
| Colonoscopy with polyp removal (snare) (45385) | 6,846 | 162 | $332.62 | 3.73% | 3.76% |
| Colonoscopy with biopsy (45380) | 6,506 | 177 | $221.03 | 3.55% | 3.16% |
| Diagnostic colonoscopy, nothing removed (45378) | 1,332 | 140 | $204.17 | 0.73% | 0.87% |
| Anesthesia for a screening colonoscopy (00812) | 3,873 | — | $91.71 | 2.11% | 2.05% |
| Anesthesia for any other colonoscopy (00811) | 6,416 | — | $117.22 | 3.50% | 3.74% |
| Screening stool test for blood (FIT) (G0328) | 2,189 | 51 | $17.66 | 1.19% | 1.09% |
| Screening stool test for blood (guaiac) (82270) | 286 | 83 | $4.22 | 0.16% | 0.40% |
| Screening flexible sigmoidoscopy (G0104) | 18 | 12 | $72.31 | 0.01% | 0.01% |
Distinct Original Medicare beneficiaries with each service billed by a Utah clinician in 2024, facility and office rows combined; the approved amount is the Utah facility-setting average. A person can appear under more than one code (a biopsy and a polyp removal on the same day are separate lines), so rows do not sum to people. Clinician counts are facility-row billers. Source: CMS, Medicare Physician & Other Practitioners — by Geography and Service, 2024 — data.cms.gov; denominators from CMS, Medicare Monthly Enrollment, 2024.
Share of people with Part B in Original Medicare who had each service billed in 2024; Utah bars solid, national bars lighter; bars scaled to the largest value. Source: CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024.
Utah runs 1.20 times the national rate for colonoscopies billed purely as screenings, about the national rate for colonoscopies in which a polyp was removed (0.99 times), 1.12 times for a biopsy, and below the nation for diagnostic colonoscopies with nothing removed (0.84 times). Counting anesthesia claims as a floor, at least 10,289 Utahns in Original Medicare, 5.61%, had a colonoscopy of some kind in 2024, against 5.80% nationally. The pattern is consistent with a state where more people show up for the routine test and fewer of them turn out to have something to remove, which is what the cancer registry in the next section would predict. The yearly stool test is slightly more common in Utah too (1.09 times the national FIT rate), and the sigmoidoscopy has all but vanished: 18 Utahns in a year.
The CDC's survey tells a less flattering story, because it covers a different group. PLACES estimates the share of adults 45 to 75 who are up to date on colorectal cancer screening by any method, and for Utah the population-weighted figure across the 29 counties is 63.1%, against 66.3% nationally; 25 of 29 counties are below the national figure. That range starts at 45, so most of the people in it are not on Medicare, and it is the 45-to-64 group, insured through work or the Marketplace with a deductible to meet, where Utah lags. By the time Utahns reach Medicare and the test is $0, the claims suggest they catch up. If you are helping an adult child or a spouse under 65 decide, that is the group the gap is in.
Why does screening still matter in the state with the lowest colorectal cancer rate?
Utah has less colorectal cancer than any other state, and it is not close. The NCI and CDC's State Cancer Profiles put Utah's age-adjusted incidence at 30.4 new cases per 100,000 people a year for 2019–2023, against 36.9 nationally, which ranks Utah last of the 50 states and the District of Columbia, 0.82 times the national rate. Among people 65 and older it is 116.6 against 152.7, again the lowest in the country and 0.76 times the national figure. The death rate for 2020–2024 is 10.8 per 100,000 against 12.7. The likeliest reasons are the ordinary ones for Utah: low rates of smoking and drinking, a younger population (the rates above are age-adjusted, so that is already accounted for), and a long habit of screening.
Source: National Cancer Institute and CDC, State Cancer Profiles, colon and rectum cancer, age-adjusted incidence 2019–2023 (all ages, ages 65+, and late stage) and death rates 2020–2024, November 2025 data submission — statecancerprofiles.cancer.gov.
The late-stage share is the number to sit with. Six in ten Utah colorectal cancers are regional or distant when found, the same share as the nation, and the point of screening is to find polyps before they are cancers and cancers before they spread. A low statewide rate is good news about how many Utahns will ever face the disease; it says nothing about whether the polyp in any one person's colon is there. The county table below pairs each county's screening rate with its cancer rate. The counties with the lowest screening, Uintah, Duchesne, Tooele, San Juan and Sanpete, are rural or exurban, and several of the highest cancer rates, Juab, Grand, Millard, Carbon and San Juan, are in counties with no gastroenterologist listed in CMS's file. Small counties have wide margins of error on both figures, and seven have too few cases for a rate at all.
| County | Adults 45–75 up to date on screening, % (2022) | Colorectal cancer cases per 100,000, 2019–2023 | County | Adults 45–75 up to date on screening, % (2022) | Colorectal cancer cases per 100,000, 2019–2023 |
|---|---|---|---|---|---|
| Uintah | 55.5% | 29.9 | Carbon | 63.1% | 37.8 |
| Duchesne | 55.8% | 34.1 | Davis | 63.3% | 29.2 |
| Tooele | 56.3% | 30.2 | Rich | 63.3% | suppressed |
| San Juan | 56.4% | 36.6 | Grand | 63.4% | 40.2 |
| Sanpete | 57.3% | 29.2 | Wayne | 63.4% | suppressed |
| Millard | 57.8% | 38.7 | Beaver | 64.2% | suppressed |
| Cache | 58.3% | 28.7 | Washington | 64.6% | 28.1 |
| Iron | 59.0% | 30.5 | Morgan | 64.8% | 27.3 |
| Piute | 59.6% | suppressed | Salt Lake | 65.3% | 29.3 |
| Juab | 60.2% | 42.6 | Garfield | 66.2% | suppressed |
| Sevier | 61.5% | 30.1 | Kane | 66.8% | suppressed |
| Utah | 61.9% | 33.6 | Daggett | 66.9% | suppressed |
| Weber | 61.9% | 33.1 | Summit | 67.0% | 25.5 |
| Box Elder | 62.0% | 31.0 | Wasatch | 67.4% | 27.7 |
| Emery | 62.7% | 34.1 |
Screening: adults 45 to 75 who are up to date on colorectal cancer screening by any recommended method, crude (not age-adjusted) model-based estimates from the 2022 Behavioral Risk Factor Surveillance System, sorted lowest to highest; the United States figure is 66.3% and Utah's population-weighted figure is 63.1%. Source: CDC PLACES, county data, 2025 release — data.cdc.gov. Cancer: age-adjusted incidence of colon and rectum cancer, all ages, 2019–2023; “suppressed” means three or fewer cases a year; 22 of 29 counties have a rate. Source: NCI and CDC, State Cancer Profiles, Utah by county — statecancerprofiles.cancer.gov.
For a rural reader the practical point is the same one that runs through our skin cancer and joint replacement guides: the cost of a Medicare-covered test includes the drive. A Uintah Basin or San Juan County patient's nearest listed gastroenterologists are in Salt Lake County or St. George, several hours each way, with a prep the day before and a driver required the day of. That is one argument for the stool and blood tests, which can be done from home with a kit and a referral, as long as you understand that a positive result means the colonoscopy anyway. In rural Utah, colonoscopies are also done by general surgeons and some family physicians at the local hospital; they are not in the gastroenterologist count below, and Medicare covers the test the same way whoever does it.
Can you find a Utah gastroenterologist who takes Medicare?
Yes, and nearly all of them accept assignment. CMS's clinician file lists 121 clinicians with a Utah practice location whose primary specialty is gastroenterology, and 117 of them, 97%, accept the Medicare-approved amount as payment in full. The other 4 are non-participating and may charge up to 15% more than the approved amount, which on a $332.62 fee would be about $49.89; Medigap Plan G pays that excess charge and Plan N does not. A separate 12 clinicians list colorectal surgery as their primary specialty, 11 of them accepting assignment. With Original Medicare you need no referral to see any of them. The file lists clinicians by the practice address they enrolled with, so a group's billing office can inflate a small town's count; Fillmore's seven reflect a group enrolled at a Fillmore address.
| City or area | Gastroenterologists with a practice location (CMS, Oct. 2026) |
|---|---|
| Salt Lake City | 63 |
| Murray | 12 |
| Provo | 8 |
| St. George | 8 |
| Ogden | 8 |
| Fillmore | 7 |
| Sandy | 7 |
| Layton / Farmington | 7 |
| Riverton / South Jordan / Draper | 7 |
| West Jordan | 5 |
| American Fork / Lehi | 5 |
| Logan | 3 |
| West Valley City | 3 |
| Cedar City | 2 |
| Bountiful | 2 |
| Park City | 2 |
| Brigham City | 1 |
Clinicians whose primary specialty in the CMS file is gastroenterology, counted once per clinician per city; a doctor who practices in two cities appears under both, so the column does not sum to 121. No gastroenterologist is listed with a practice location in Moab, Vernal, Roosevelt, Price, Richfield, Kanab, Blanding, Monticello, Tooele or Nephi. Source: CMS, Doctors and Clinicians National Downloadable File — data.cms.gov.
How do Medicare Advantage and Medigap each handle a colonoscopy?
More than half of Utah's Medicare population, 269,226 of 490,235 people in June 2026, is in a Medicare Advantage plan. Medicare.gov's rule is that these plans must cover everything Original Medicare covers, so every test in the first table is covered, and a Medicare-covered preventive screening in network is generally the plan's $0 benefit too. The differences are structural. You will need a gastroenterologist, a surgery center or hospital and an anesthesia group that are all in the plan's network; in most HMOs you will need a referral from your primary care doctor first; and if a polyp is removed, or the colonoscopy was ordered for symptoms, the cost-sharing is the plan's, usually a flat copay for an outpatient diagnostic procedure or outpatient surgery, rather than Medicare's 15% or 20%. Some plans require prior authorization for a diagnostic colonoscopy or for the anesthesia; a screening one rarely needs it. The plan's in-network out-of-pocket maximum caps the year. A $0-premium plan is not free: you still pay the Part B premium, $202.90 a month in 2026 for most people, and the plan's copays. Read the Evidence of Coverage lines for “colorectal cancer screening,” “outpatient diagnostic procedures” and “outpatient surgery” before the date is set, and confirm all three providers are in network.
In Original Medicare with a Medigap policy, each bill is the Medicare amount described above, and the policy pays it. Plan G pays the 15% on the doctor, the facility and the anesthesia, the 20% on the pathology and on any diagnostic colonoscopy, and any excess charge, leaving you the $283 Part B deductible if a diagnostic bill applies it; a pure screening never does. Plan N pays the same except a copay of up to $20 for office visits, which would apply to the consultation beforehand, not the procedure, and it leaves you with excess charges from the 4 non-participating gastroenterologists. There is no network, no referral and no authorization, and you may choose any doctor and any facility that takes Medicare. The 221,009 Utahns in Original Medicare with no Medigap policy are the ones paying the $166 to $251 in the tables above when a polyp is found, which, for a test most people have once a decade, is a modest sum; the diagnostic colonoscopy for a symptom, at 20% plus the deductible, is the one that costs real money without a policy. Our Plan G vs. Plan N guide and Medigap vs. Medicare Advantage guide weigh the two paths for a whole year of care, not one test.
A Logan example: a screening colonoscopy that found a polyp
Consider a 66-year-old retired dairy-equipment salesman in Cache County who enrolled in Original Medicare last year and has never had a colonoscopy. Cache County's screening rate, 58.3%, is among the lowest in the state. At his yearly Wellness visit his doctor notes the gap and refers him to one of the 3 gastroenterologists listed in Logan, who schedules a screening colonoscopy at a surgery center with an anesthesia professional. The doctor finds one small polyp and removes it with a snare; it goes to a pathology lab and comes back benign. Because the test began as a screening, the doctor bills the polyp-removal code with the screening modifier, and at 2024 Utah averages and the January 2026 surgery center rate the Medicare-approved amounts look like this:
| Step | Medicare-approved amount | Your share in 2026 (Original Medicare, no Medigap) |
|---|---|---|
| Gastroenterologist's fee, colonoscopy with snare polyp removal (45385, billed with the screening modifier), Utah 2024 average | $332.62 | $49.89 (15%) |
| Surgery center facility fee, January 2026 national rate | $656.75 | $98.51 (15%) |
| Anesthesia professional fee (00811), Utah 2024 average | $117.22 | $17.58 (15%) |
| Total (pathology lab's fee and the pre-procedure office visit not included) | $1,106.59 | $165.99 |
Illustrative; averages across all Utah claims for each code in 2024 and CMS's national January 2026 ASC rate, not a price quote. Sources: CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024; CMS, January 2026 ASC Addendum AA; CMS MLN Matters MM12656.
Had the polyp not been there, every line would read $0.00 and no deductible would apply. With Plan G or Plan N he owes nothing for the procedure either way (Plan N's $20 copay applies to the consultation visit). In Original Medicare with no Medigap policy he owes about $165.99 plus the pathology bill, and had the same procedure been done in the hospital outpatient department across town he would have paid about $84.85 more. In a Medicare Advantage HMO he would have needed the referral first, an in-network center and anesthesia group, and would owe the plan's outpatient diagnostic or surgery copay instead of the 15%; whether that is more or less than $165.99 depends on the plan. Because a polyp was found, his gastroenterologist will likely recommend a repeat in three to five years rather than ten, and Medicare's high-risk schedule (every 24 months) now covers him, since a personal history of adenomatous polyps is on the list. If he waits until 2027 the share on the next one is 10%; by 2030 it is nothing.
What should a Utah retiree actually do?
- Ask how the colonoscopy will be billed before you schedule it: screening or diagnostic. If you have no symptoms and are due, it is a screening, and it should be $0 unless a polyp is removed. If you mention a symptom, the doctor may be obliged to order it as diagnostic, at 20% plus the deductible. Know which it is before the prep.
- If a positive stool or blood test led to the colonoscopy, make sure it is billed as the follow-up screening. Since 2023 that colonoscopy is a screening with no cost-sharing, and the frequency limits do not apply to it. If a bill arrives showing 20% and a deductible, call the office and cite the “complete colorectal cancer screening” rule.
- Confirm the doctor, the facility, the anesthesia group and the pathology lab all accept assignment. 97% of Utah's gastroenterologists do. The pathology lab is the one most people forget, and it is the one bill the reduced-coinsurance rule does not cover.
- Choose the setting with the bill in mind. A surgery center costs an Original Medicare patient about $84.85 less than a hospital outpatient department in 2026 when a polyp is found and the same ($0) when it is not. Your doctor's judgment about where you should be sedated comes first.
- If you are in Medicare Advantage, get the referral and confirm the network for all three providers before the date is set, and read the plan's copay for outpatient diagnostic procedures, which is what applies if a polyp is removed. Ask whether the plan requires prior authorization for a diagnostic colonoscopy.
- If a colonoscopy is impractical where you live, ask about the stool or blood test. The FIT test is yearly and the stool DNA and blood tests are every three years at $0 for people 45 to 85 at average risk, done from home with a referral. Just understand that a positive result means the colonoscopy anyway, and that the three-year tests are not for people with a history of polyps or a family history.
- Use the Wellness visit to set the schedule. Medicare pays for a yearly Wellness visit in which the doctor writes down which screenings you are due for and when; colorectal screening belongs on that list, with your risk category and the date of your last test. Past 75, discuss whether to continue.
- Match your coverage to the tests you expect. One screening colonoscopy a decade is not a reason to buy a Medigap policy, but a history of polyps, a family history or a chronic condition that will bring diagnostic colonoscopies at 20% plus the deductible is part of the calculation. The Annual Enrollment Period (October 15 to December 7) is the time to weigh Medigap against Medicare Advantage; note that in Utah a Medigap application outside your first six months of Part B can be medically underwritten.
We help Utah retirees understand what their Medicare coverage pays for, including how Medigap and Medicare Advantage each handle screenings, diagnostic procedures and the bills that come with a polyp, and how it fits with long-term care protection and retirement income. Plain English, no pressure. Education, not advice. We do not offer every plan available in your area.
Talk to a planner →Frequently asked questions
Does Medicare cover a colonoscopy?
Yes. Medicare Part B covers a screening colonoscopy once every 120 months (10 years) if you are not at high risk for colorectal cancer, or 48 months after a flexible sigmoidoscopy, and once every 24 months if you are at high risk, which Medicare defines as a personal history of colorectal cancer, adenomatous polyps or inflammatory bowel disease, or a close relative with colorectal cancer or adenomatous polyps. There is no minimum age and no deductible, and if your doctor accepts assignment you pay nothing for the test itself. A colonoscopy ordered because of symptoms is a diagnostic test, which Part B also covers, but under the ordinary rules: 20% of the Medicare-approved amount after the $283 Part B deductible in 2026. In 2024, 3,957 Utahns in Original Medicare had a colonoscopy billed as a screening and at least 10,289 had a colonoscopy of some kind.
How much does a colonoscopy cost with Medicare in Utah in 2026?
A clean screening colonoscopy costs $0: CMS's 2024 claims file shows Medicare paid 100% of the approved amount on every Utah screening colonoscopy and its anesthesia. If the doctor finds and removes a polyp, which happened on 6,846 Utah colonoscopies in 2024, the test is still treated as a screening but you pay 15% of the Medicare-approved amount to the doctor and 15% to the facility, with no deductible. At the 2024 Utah average gastroenterologist's fee of $332.62, the 2024 Utah average anesthesia fee of $117.22 and Medicare's January 2026 facility rates, that is about $166 in an ambulatory surgery center ($656.75 facility rate) and about $251 in a hospital outpatient department ($1,222.44), before the pathology lab's separate bill. The coinsurance falls to 10% in 2027 and to nothing in 2030. A Medigap Plan G or Plan N policy pays the 15%.
Does Medicare cover Cologuard, the FIT stool test or the new blood test?
Yes, all three, at $0 if the provider accepts assignment. A stool test for blood (the guaiac test or the immunochemical FIT) is covered once every 12 months for people 45 and older with a referral. The multi-target stool DNA test (Cologuard) and a blood-based biomarker test are each covered once every 3 years for people 45 to 85 who have no symptoms and are at average risk, meaning no personal history of polyps, colorectal cancer or inflammatory bowel disease and no family history of colorectal cancer or polyps. Since January 1, 2025 Medicare also covers a CT colonography every 60 months at average risk or every 24 months at high risk. If any of these tests is positive, the follow-up colonoscopy counts as a screening too, so it is $0 unless a polyp is removed. Nationally, 624,969 people in Original Medicare had the stool DNA test in 2024 and 3,543 had the blood test; Utah's tests do not appear in the Utah rows because the laboratory that bills them is in another state.
Why do I owe money for a screening colonoscopy if a polyp was removed?
Because the moment a polyp or tissue is removed, the procedure becomes a therapeutic or diagnostic service under Medicare law, and Congress chose to phase the patient's share out rather than end it at once. Section 122 of the Consolidated Appropriations Act of 2021 set the schedule CMS now follows: 15% coinsurance for 2023 through 2026, 10% for 2027 through 2029, and no coinsurance from 2030, with the Part B deductible waived throughout. Before 2023 the share was the full 20% plus the deductible. The same rule applies to a screening flexible sigmoidoscopy. The pathology laboratory's fee for examining the removed tissue is a separate claim that the reduced-coinsurance rule does not list, so expect ordinary Part B cost-sharing on that bill unless you have a Medigap policy.
Is a colonoscopy covered by Medicare Advantage?
Yes. Medicare Advantage plans must cover every screening test Original Medicare covers, and more than half of Utah's Medicare population, 269,226 of 490,235 people in June 2026, is in one. The differences are the plan's: you will generally need an in-network gastroenterologist or surgery center, a referral from your primary care doctor in most HMOs, and, if a polyp is removed or the colonoscopy is diagnostic, the plan's own copay for outpatient surgery or diagnostic procedures rather than Medicare's 15% or 20%. Some plans require prior authorization for a diagnostic colonoscopy. Check your Evidence of Coverage for the lines on preventive screening, outpatient diagnostic procedures and outpatient surgery, and confirm the doctor, the facility and the anesthesia group are all in network before the date is set.
How common is colorectal cancer in Utah, and should I still get screened if the rate is low?
Utah has the lowest colorectal cancer incidence of any state: 30.4 new cases per 100,000 people a year in 2019-2023 against 36.9 nationally, and 116.6 against 152.7 among people 65 and older, according to the NCI and CDC's State Cancer Profiles. It is still Utah's most common cancer of the digestive tract, with about 903 new cases and 319 deaths a year, 424 of the cases in people 65 and older, and 60.3% of Utah cases are found at a late (regional or distant) stage, the same share as the nation. A low rate changes how many Utahns get the disease; it does not change what screening does for the person who has a polyp, which is to remove it before it becomes cancer. The CDC estimates 63.1% of Utah adults 45 to 75 are up to date on screening against 66.3% nationally, with 25 of 29 counties below the national figure.
Sources
- Medicare.gov — Colonoscopies (screening) (Part B covers screening colonoscopies; no minimum age; every 24 months at high risk, every 120 months otherwise or 48 months after a flexible sigmoidoscopy; $0 with assignment; 15% to the provider and 15% to the facility if a polyp or tissue is removed, deductible waived; follow-up colonoscopy after a positive stool or blood test is a screening): medicare.gov — colonoscopies; Fecal occult blood tests (45 and older, referral required, every 12 months, $0): medicare.gov — fecal occult blood tests; Multi-target stool DNA tests (45–85, no symptoms, average risk, every 3 years, $0): medicare.gov — stool DNA tests; Blood-based biomarker tests for colorectal cancer screening (45–85, average risk, every 3 years, $0): medicare.gov — blood-based tests; Computed tomography (CT) colonography (screening) (45 and older; every 24 months at high risk, 60 months otherwise; $0): medicare.gov — CT colonography; Flexible sigmoidoscopies (45 and older; every 48 months; 15% if a growth is removed): medicare.gov — flexible sigmoidoscopies
- Medicare.gov — Does your provider accept Medicare as full payment? (assignment; non-participating providers; the 15% limiting charge): medicare.gov — assignment; Compare Original Medicare & Medicare Advantage (plans must cover all Part A and Part B services; networks and referrals): medicare.gov — compare coverage options; Yearly “Wellness” visits (written screening schedule): medicare.gov — wellness visits
- CMS — MLN Matters MM12656, “Colorectal Cancer Screening Tests: Changes to Coinsurance for Related Procedures” (Consolidated Appropriations Act of 2021, section 122: coinsurance 15% for 2023–2026, 10% for 2027–2029, none from 2030, when a screening colonoscopy or sigmoidoscopy becomes a diagnostic or therapeutic service; applies to procedure codes 10000–69999, G0500, 00811 and 99153 billed with the PT modifier): cms.gov — MM12656 (PDF)
- CMS — MLN Matters MM14031, “Updates to Colorectal Cancer Screening & Hepatitis B Vaccine Policies” (effective January 1, 2025: barium enema removed, CT colonography (74263) added, blood-based biomarker tests added to the complete-screening continuum, frequency limits do not apply to the follow-on screening colonoscopy): cms.gov — MM14031 (PDF); Calendar Year 2025 Medicare Physician Fee Schedule Final Rule fact sheet (colorectal cancer screening changes): cms.gov — CY 2025 PFS final rule; National Coverage Determination 210.3, Colorectal Cancer Screening Tests (definitions of high risk and average risk; FOBT every 12 months from age 45; non-invasive biomarker tests every 3 years, ages 45–85): cms.gov — NCD 210.3
- CMS — 2026 Medicare Parts A & B Premiums and Deductibles, November 14, 2025 (Part B premium $202.90; Part B deductible $283): cms.gov — 2026 premiums and deductibles
- CMS — ASC Payment Rates Addenda, January 2026 (Addendum AA: ASC rates $510.49 for G0121, G0105 and 45378 and $656.75 for 45380, 45384 and 45385; Addendum FF: January 2026 OPPS rates $950.19 for APC 5311 and $1,222.44 for APC 5312), from the CY 2026 OPPS/ASC final rule: cms.gov — ASC addenda
- CMS — Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (Utah and National rows for G0121, G0105, G0104, 45378, 45380, 45385, G0328, 82270, 81528, G0327, 00812 and 00811; beneficiaries, clinicians, average approved and paid amounts): data.cms.gov — physician & other practitioners by geography and service
- CMS — Medicare Monthly Enrollment (2024: 183,494 Utahns and 27,982,142 nationally with Part B in Original Medicare; June 2026: 490,235 Utah beneficiaries, 269,226 in Medicare Advantage, 221,009 in Original Medicare): data.cms.gov — monthly enrollment
- CMS — Doctors and Clinicians National Downloadable File, retrieved October 6, 2026 (121 Utah gastroenterologists, 117 accepting assignment; 12 colorectal surgeons; city counts): data.cms.gov — doctors and clinicians
- CDC — PLACES: Local Data for Better Health, county data, 2025 release (colorectal cancer screening among adults 45–75, crude prevalence, 2022 BRFSS, all 29 Utah counties; United States 66.3%): data.cdc.gov — PLACES
- National Cancer Institute and CDC — State Cancer Profiles, colon and rectum cancer: age-adjusted incidence by state 2019–2023, all ages (Utah 30.4, U.S. 36.9) and ages 65+ (Utah 116.6, U.S. 152.7); late-stage incidence and share (Utah 18.3, 60.3%; U.S. 22.3, 60.2%); death rates 2020–2024 (Utah 10.8, U.S. 12.7); Utah counties: statecancerprofiles.cancer.gov — Utah counties
- Utah Insurance Department — Medicare consumer page (Utah SHIP (877) 424-4640): insurance.utah.gov
About this article. Written by the Utah Retirement Income Data Desk and reviewed by Brian Penner, Retirement income & long-term care planner. Educational only — not medical, financial, or legal advice, and not a recommendation of any specific plan, provider, facility, laboratory or test; whether, when and how to be screened for colorectal cancer is a decision for you and your doctor. Coverage rules and cost-sharing are quoted from Medicare.gov and CMS as of October 6, 2026; the Utah and national beneficiary counts, shares and average amounts are our own tabulation of the CMS Physician & Other Practitioners, Doctors and Clinicians and Medicare Monthly Enrollment public use files, which count Original Medicare claims only, attribute each claim to the state of the clinician, and are revised by CMS periodically; a person can appear under more than one billing code; the screening-rate figures are CDC model-based estimates and the cancer figures are registry rates, each with the limitations noted on its source page. ASC and hospital outpatient rates are CMS's national January 2026 figures before geographic adjustment; average Medicare-approved amounts are averages across all claims and are not price quotes; the example household is illustrative. What you will owe depends on your coverage, your doctor, the facility, how the procedure is ordered and billed, and whether each provider accepts assignment or is in your plan's network; confirm with your plan, your provider, or 1-800-MEDICARE before you act. Utah Retirement Income is a licensed independent insurance agency (NPN 16493717) and is not a government agency; we are not connected with or endorsed by Medicare, the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the National Cancer Institute, the Social Security Administration, or any government program, and nothing here should be read as an endorsement by them. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area; please contact Medicare.gov, 1-800-MEDICARE, or your State Health Insurance Assistance Program — in Utah, the Utah SHIP at (877) 424-4640 — to get information on all of your options. A $0-premium Medicare Advantage plan is not free; you still pay the Part B premium ($202.90 a month in 2026 for most people) and the plan's cost-sharing. Long-term care insurance and annuity guarantees depend on the claims-paying ability of the issuing company, with no promise of savings. If you call or text us, you consent to be contacted at the number you provide about your options; message and data rates may apply, and you can opt out at any time by replying STOP.