r/HealthInsurance • u/pinkyoshimitsu • Jun 04 '25
Medicare/Medicaid Colonoscopy needed but no insurance
My close 26yo friend lives near Atlanta, GA. She works part-time at a church doing childcare and part-time at HomeGoods. Along with her younger brother, she helps support her household, particularly her older sister (who has MS but seems to not qualify for disability?), and her mother (disabled + ex-alcoholic with dementia).
About five years ago, she had serious GI issues and got a colonoscopy (discounted by a friendly doctor), which found large tumors in a part of the colon known for aggressive precancerous growth. The doctor advised repeat colonoscopies every 1–3 years, but she hasn’t had one since due to a lack of insurance.
Given her part-time jobs and financial situation, would she likely qualify for Georgia Medicaid? And if not, would she be eligible for subsidized ACA marketplace insurance? Or are there any other resources or clinics in Georgia that might help her get a follow-up colonoscopy without insurance?
Thanks in advance for any advice or info, I really appreciate it.
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u/Initial_Freedom7981 Jun 05 '25
Unfortunately Georgia is one of the few states that has not expanded Medicaid, so your friend likely will not qualify. Medicaid expansion allows anyone under the income limits to qualify, even if they are not a child/elderly/pregnant/disabled. They can buy insurance on the marketplace healthcare.gov, but without a qualifying life event that con only be done during open enrollment in November. Your friends best option is to get a job that offers insurance like Starbucks
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u/FlourideDonut Jun 05 '25
Worse. Georgia pioneered Medicaid work requirements so OP’s friend likely can’t reduce hours to decrease income to gain Medicaid eligibility.
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u/Initial_Freedom7981 Jun 05 '25
That’s a moot point. She doesn’t qualify for Medicaid regardless because there’s no expansion in GA. She could get a DIFFERENT job that offers health insurance though
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u/pinkyoshimitsu Jun 05 '25
That’s unfortunate. Perhaps symptoms of colon cancer (especially with a history of having developed large precancerous tumors five years prior) could be a qualifying life event?
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u/Initial_Freedom7981 Jun 05 '25
Unfortunately no. If that’s how it worked, no one would have insurance until they needed it, and is part of why the ACA was passed. Qualifying life events include loss of ACA compliant coverage, marriage, birth of a child, etc. you can look them up. Frankly, while this is a very though situation it’s kind of shocking your friend has gone without insurance for so long knowing they have this health condition. They have had opportunities each year to get insurance on the marketplace, or to get a job that offers insurance.
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u/HazelFlame54 Jun 05 '25
Change of job is a qualifying event. That’s worth looking into.
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u/Initial_Freedom7981 Jun 05 '25
No it’s not. It’s only a QLE if you had ACA compliant insurance at that job, and lose the insurance because you left the job. So it’s not a QLE for the marketplace. But, getting a new job may allow you to get insurance because the job will create a special enrollment period for you if they offer insurance, to enroll in their own insurance plan.
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u/rosebudny Jun 05 '25
That absolutely would not be a qualifying life event. The reason you can only enroll during certain windows is to avoid exactly this - people waiting until they are sick to sign up for insurance.
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u/pinkyoshimitsu Jun 05 '25
That makes sense, definitely gives much more context to the open enrollment limits
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u/Shitp0st_Supreme Jun 05 '25
Nope. And colonoscopies for insurance are only covered as a routine screening and if it’s to check on symptoms, it’s no longer covered.
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u/pinkyoshimitsu Jun 05 '25
So even if she had insurance, she couldn’t just get a colonoscopy unless it was a recommended routine check-up or due to heightened symptoms? Wouldn’t she still qualify given that she was recommended by the doctor to have them regularly — not to mention that sometimes her symptoms come back
7
u/Annoyedbyme Jun 05 '25
No. She can get one. But it won’t be 100% paid for and if the plan is a high deductible one, again friend would likely be paying for the scope or a big chunk anyway.
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u/Shitp0st_Supreme Jun 05 '25
I would 100% suggest she apply for Medicaid asap. I’m not sure if she will be eligible, but she won’t be penalized for applying if she’s not eligible. All that happens is that she will be told she isn’t eligible. It sounds like other commenters more familiar with Georgia said that there’s no Medicaid expansion which sucks, I’m not sure if she could move states but a state with expanded Medicaid could be lifechanging for her especially since she cares for people with chronic health conditions.
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u/Shitp0st_Supreme Jun 05 '25 edited Jun 05 '25
She could get one but it just wouldn’t be covered by insurance. If she had a typical deductible plan through her work and she had the plan that was the cheapest premium every month, she’d likely have a deductible of $5,000 to $7,000 which means she’d have to pay up to $7,000 in medical bills through insurance in that year before she would be covered for 80% of the service costs until she met her max out-of-pocket. This would be for in-network providers.
Check to see if she’s eligible for a marketplace plan or Medicaid. It’s better than nothing and then she can see if the doctor can do screening or exams that are covered.
The fact is that only routine screening colonoscopies are covered by insurance, and screenings are for adults 50 and older who don’t have symptoms. The moment the colonoscopy becomes a diagnostic screening due to symptoms, it’s considered a diagnostic colonoscopy and it is not covered by insurance. Even if a doctor orders it for her due to symptoms, that doesn’t make a difference. I’ve heard stories where people had a routine colonoscopy and then the doc would see a polyp and biopsy it while they were there, and then since a biopsy was done, the colonoscopy was coded as if it was done as a treatment and not a screening and then insurance wouldn’t cover it.
So unless she has insurance, and is over 50 and has no symptoms, or is insured and has met her deductible, a colonoscopy will not be covered.
I will say that I have great insurance and was looking to get a colonoscopy and I talked to my doctor and she thought my symptoms could be endometriosis and then I was able to get surgery to check for that (which has been billed at over $20k so far, claims are still processing but I only had to pay $67) and it ended up being endometriosis. If her symptoms seem to come and go and aren’t related to diet, see if she can log them and if she finds trends with her menstrual cycle, that could be something.
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u/UnderABig_W Jun 05 '25
If you read the post, you’ll see the person in question had a previous colonoscopy in which large polyps were discovered (OP said tumors, but I’m pretty sure she meant polyps.). So she needs a colonoscopy. It’s not endometriosis.
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u/Queenof6planets Jun 05 '25
no, non-preventative care is still covered by insurance. you’d have to pay the deductible and copay, but that’s not the same as not being covered at all.
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u/Fluid-Power-3227 Jun 05 '25
Contact The Urban Clinic of Atlanta. They offer healthcare for the uninsured. Explain your friend’s situation and see if they can help you. Often teaching hospitals, like Emory, have clinic programs and receive funds for charity care.
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u/CatPesematologist Jun 05 '25
She could try Georgia Pathways, although they are literally paying more for administration than on claims.
Anything to keep people desperate, I suppose.
https://dch.georgia.gov/georgiapathways
She could also get care at a FQHC. Ideally they might have ideas that could her get what she needs.
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u/LibraryMegan Jun 05 '25
Starbucks and Lowe’s are two places that offer health insurance, but there are others. Her only option until November is going to be to get a job with health insurance as a benefit.
If she waits until November, she can purchase a plan through the marketplace that will begin coverage in January. If she doesn’t have employee coverage by then, she really needs to sign up for an ACA marketplace plan at that time or she will be without insurance for another year.
Georgia did not expand Medicaid, as others are explaining to you. So there is no low income insurance available in your state.
10
u/katsrad Jun 05 '25
It looks like Georgia did not expand Medicaid so that's likely not an option. Signing up for the marketplace is not possible currently as it is outside open enrollment. They are able to enroll in November for a January effective date. They may qualify for a premium subsidy.
The best option right now is talking to a hospital/providers office to see if they offer discounted rates for cash payment.
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u/alb_taw Jun 05 '25
Not just discounted rates for cash - every nonprofit hospital should have a charitable care policy. Check online or call as many as possible to find one that will cover all or most of the cost. Make sure it covers the physician and anesthesia as well as any hospital services.
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u/pinkyoshimitsu Jun 05 '25
To pay directly for a colonoscopy, you mean? And does the open enrollment period limit also apply to directly applying for a health insurance without the ACA marketplace?
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u/katsrad Jun 05 '25
Yes pay directly for a colonoscopy. There are plans available outside the marketplace but they are not aca compliant and don't have to cover preexisting conditions so may not cover a colonoscopy since it is a prior condition.
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u/pinkyoshimitsu Jun 05 '25
That’s kinda crazy that they can just say “no” to low-income people with significant medical issues. Hopefully we might find a non-ACA insurance that is affordable and would cover it.
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u/laurazhobson Moderator Jun 05 '25
It is not the ACA that is blocking poor people from accessing medical care.
It is the politicians in ten states including Georgia which deliberately chose not to take Federal funding to expand Medicaid. It was a political action rather than one based on any kind of valid public policy - let alone a scintilla of compassion.
The ACA was designed to work in conjunction with expanded Medicaid. The truly poor would get Medicaid. Those who made enough would get insurance through the marketplace with a subsidy that was designed to make the premiums affordable since they are based on income.
The ACA provided Federal funding for the expansion of Medicaid. I believe it was about 90% that the Federal government would contribute which made the non-expansion not make any kind of sense.
Not only does it punish poor people but it also creates a situation which increases medical costs for others and deprives hospitals of needed revenues. The very poor still have to be treated for emergencies at hospitals.
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u/katsrad Jun 05 '25
Be very very careful about nonACA plans. They can have very limited coverage. Another person mentioned starbucks as an option for an employer that offers health coverage for part time employees so that could be an option.
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u/Actual-Government96 Jun 05 '25
Non ACA plans will either decline to cover her entirely or exclude anything related to her colon issue (pre-existing).
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u/NewIndependence Jun 05 '25
You will be wasting your money. Non ACA plans are horrible, purely because they dont have to comply with ACA.
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u/look2thecookie Jun 05 '25
You won't. It is crazy, but also there are plenty of ways to get insurance, you just have to follow the rules. You don't get a la carte insurance when you want services, you get it year round and there are times you sign up or renew every year.
There are also states that allow people like your friend to get Medicaid, but certain states, like GA, FL, TX, and all the ones that have the most legislation that hurts low income people, don't offer expanded medicaid. They intentionally choose to screw their citizens over.
So yeah, insurance sucks, but it sucks more in some places and you also have to be an adult and follow the rules.
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u/IcyChampionship3067 Jun 05 '25
It's exactly what the government in GA has promised for years. They got elected promising this. I'm sorry this is happening, but it's certainly shouldn't be a surprise.
Apply for Medicaid. Get denied. Then, begin the process for the ACA. She may have to wait until open enrollment a few months from now.
It's unlikely she'll find insurance otherwise.
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u/pinkyoshimitsu Jun 05 '25
From what I’m hearing non-ACA insurance wouldn’t be worth it because it most likely wouldn’t cover the colon cancer issues, and would also just be generally shit. So yeah I guess waiting for the ACA open enrollment at the end of the year or doing employer-based would be the best. There could be some medical finance organizations that might be able to help subsidize the colonoscopy.
6
u/climbing_butterfly Jun 05 '25
You're confusing 2 things. Your state did not expand Medicaid that's the issue. Your state doesn't care about poor people with health issues... Prior to the ACA 2008 all insurance denied or charged hire premiums. The ACA made that illegal. There are non compliant plans that deny people with pre-existing conditions because a colonoscopy and treatment is expensive and they are in the business to make money. Your friend's health costs them money
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u/nunyabizz62 Jun 05 '25
Maybe a trip to Mexico
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u/pinkyoshimitsu Jun 05 '25
Will look into that. I’m assuming that would substantially reduce the cost of paying out of pocket for the colonoscopy directly?
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u/nunyabizz62 Jun 05 '25
It should be cheaper, I know dental sure is. Things have changed past few years because the US has gone insane.
This link is also a possibility.
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u/CA-girl2398 Jun 06 '25
I just got a quote from Baja Endoscopic in Tijuana it was $550 for a colonoscopy. Colonoscopy Assist might be better when you consider travel costs.
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u/Tessatrala Jun 05 '25
This is a non-profit that does free outpatient procedures on Sundays in Lexington, Kentucky for income eligible people. There might be something in your friend's area that is similar.
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u/pinkyoshimitsu Jun 05 '25
Something like that would be ideal. They limit applicants to those within a 250-mile radius of Lexington Kentucky, unfortunately she is a bit closer to 300 miles away. There definitely could be something closer
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u/ElleGee5152 Jun 05 '25
I would check with the nearest university or teaching hospital and see if they offer a charity care program. GA did not expand Medicaid so getting coverage is very unlikely.
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u/Working_Coat5193 Jun 05 '25
See if there’s an outpatient colonoscopy center that she can pay cash for. It can be like $300 - $1000. Still expensive but not insane.
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u/xxvcd Jun 05 '25
Do everything possible to get that colonoscopy. Trust me…..
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u/pinkyoshimitsu Jun 05 '25
Are you speaking from experience? I’m definitely very very nervous for her.
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u/laurazhobson Moderator Jun 05 '25
If her income is no higher than 150% of Federal Poverty Level she would be able to enroll through the ACA and get an ACA compliant policy.
However she would need an income of about $20,000 to qualify for a subsidy and without a subsidy the premium would be high. However, it might be worth it.
She should get a job at Starbucks because they offer decent health insurance to part time workers - anyone working at least 20 hours per week.
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u/pinkyoshimitsu Jun 05 '25
Will have to look into Starbucks! Also a ceiling of 150% FPL seems shockingly low for the ACA marketplace? I thought it exists for pretty typical low-income unemployed people, not those a hair’s breadth from actual poverty
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u/laurazhobson Moderator Jun 05 '25
The 150% of FPL is ONLY for those very low income people to be able to get ACA insurance through the marketplace outside of Open Enrollment. It was intended as a special way for those very low income people to get insured if they make slightly more than Medicaid caps - or if they live in one of the 10 states which didn't expand Medicaid.
Since the marketplace is based on annual income some low salaried workers can get to the income necessary by taking some side hustles like cleaning, baby sitting or Door Dash so they can get the subsidy.
But yes in a state in which Medicaid has expanded the marketplace is available to anyone but the premium is based on one's salary so if one makes $25,000 per year the subsidy will be large so the premium will be close to $0 and there are additional subsidies towards the actual cost of medical care if you select the appropriate Silver Tier Plan.
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u/karsk1000 Jun 05 '25
Subsidies exist up to 400% fpl using MAGI. Best bang for buck is at right below 150% or 200%. Both give cost sharing reduction at the higher levels which reduce copays, deductible and max out of pocket.
Wording of magi is labeled as household income tho, which can be an issue.
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u/Slowhand1971 Jun 05 '25
coverage issues on a diagnostic colonoscopy are patchy at best anyway.
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u/pinkyoshimitsu Jun 05 '25
Like even if she did have insurance, you mean?
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u/Actual-Government96 Jun 05 '25
I assume they mean it wouldn't be covered at 100% (on an ACA plan) as it wouldn't be a preventive screening (no symptoms or reason to suspect an issue). That said, it's still covered, just subject to the plan cost shares (deductible/copay/coinsurance).
The comment is misleading, this is totally standard.
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u/Negative-Maintenance Jun 05 '25
Best resource near Atlanta I can think of would be https://www.mosaichealthcenter.com
I can’t say with 100% certainty that they’d be able to help, but it’s where I would start.
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u/cottonidhoe Jun 05 '25
How much money does she make? She could consider moving to a state with better medicaid options for the future, but otherwise if she makes enough to afford ACA insurance the reality is she needs to wait for open enrollment and get a colonoscopy January of next year.
It’s not “good” news but most of these posts are “needs heart surgery tomorrow…” not “needs screening every 1-3 years…” 6 months is a long time for a precancerous tumor to grow and she should have enrolled last year, but unless she can pay for it out of pocket, get a new job with insurance, or marry someone with insurance, her option is to wait.
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u/valar_mentiri Jun 05 '25
Have your friend look into this program, there are a lot of state and county governments that help facilitate cancer screening services for uninsured patients. https://www.georgiacancerinfo.org/stay-ahead-colon-cancer.aspx
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u/No-Bread-1197 Jun 05 '25
https://www.colonoscopyassist.com/Cities/Atlanta_GA_colonoscopy.html
This program works with you to schedule one for a flat fee of about a grand. If she doesn't have that much saved, she can probably crowdfund it through the church she works at.
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u/pinkyoshimitsu Jun 06 '25
Good point regarding the church fundraiser. She already created a fundraiser a few years ago for surgery for her mum but in all fairness the whole family has health issues so it wouldn’t surprise anyone
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u/mysticalbluebird Jun 05 '25
Many places will have an out of pocket discount. Get everything in writing and documented, in regards to pricing. Get the colonoscopy.
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u/CA-girl2398 Jun 06 '25
I'm in a similar boat. I have ACA insurance but considering paying out of pocket for a needed follow-up colonoscopy because my deductible is $9k and as others have said, if she's had polyps on the past it'll be considered diagnostic and she'll likely have to pay $3-5k.
I looked into Colonoscopy Assist and it sounds pretty legit. They cover all polyp removal and biopsy for a fixed price around $1300 depending where you live.
I'd suggest paying out of pocket to do the colonoscopy this year before ACA open enrollment. Then worst case if she needs further treatment, she can sign up for an ACA plan and start treatment from January.
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u/AnonFortheTimeBeing Jun 07 '25 edited Jun 07 '25
https://www.uniteddigestive.com/practice/atlanta-gastroenterology-associates/
Publishes their cash pay rates, and they are all inclusive (sedation, facility, path, etc). One I saw was $1500, but I don't know if that is totally current. Contacting the office either way is probably worth it. If they care enough to offer stuff like that they may have other resources.
Also, Catholic Charities is a network of semi autonomous regional affiliates, but the one I used to deal with working in Pharmacy was great. Actually helped a lot of people, and decently efficient at it to boot.
https://www.catholiccharitiesusa.org/
Also, this: https://chwg.org/project/no-cost-colorectal-screening-program/
https://colorectalcancer.org/resources-support/resources/financial-assistance
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