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/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/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

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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.

0

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.