A preventive colonoscopy is supposed to be free under the ACA. For many people, it is. For many others, it ends up costing several hundred dollars because of a billing technicality most doctors never mention.
The polyp removal trap
If anything is found and removed during your preventive colonoscopy, the billing code changes. CPT 45378 becomes 45385 or another therapeutic code. Several insurers then treat the entire visit as diagnostic and apply your deductible.
The ACA preventive care exemption has been litigated for years and coverage rules vary by plan and insurer. Call your insurer before you go and specifically ask: if polyps are removed during a preventive colonoscopy, do I owe anything?
The facility fee still exists even when your copay is zero
Zero copay does not mean zero cost. The hospital charges your insurer a facility fee regardless. That fee is what this tool shows.
This matters when you hit your out-of-pocket maximum or when cost-sharing applies because of a code change. The difference between a $200 facility fee and a $2,000 one can determine whether you owe nothing or several hundred dollars after a code upgrade.
Your age and history determine whether you pay anything
Routine age-appropriate screenings (50+ or 45+ depending on guidelines) with no prior history typically qualify for the full preventive exemption.
If you have a personal or family history of polyps or colon cancer, your colonoscopy may be scheduled as surveillance, not screening. Surveillance colonoscopies are coded differently and often do not qualify for the preventive exemption. Ask your doctor which category applies to you.