Jonathan Gardner, Data Manager
For a long time, persons on nearly any insurance plan have been surprised with unexpected bills after routine preventive colorectal cancer screening procedures. They might go to sleep for a regular screening colonoscopy and wake up with a bill for a diagnostic or therapeutic colonoscopy due to findings or additional procedures that took place during the screening.
One of the goals of the Affordable Care Act (ACA)[1], a comprehensive health care reform law enacted in March 2010, is to lower the costs of health care and make affordable health insurance available to more people. Section 4104 explicitly waives the beneficiary coinsurance and deductible for certain covered preventive services identified by the U.S. Preventive Services Task Force (USPSTF)[2], including colonoscopy, sigmoidoscopy, and fecal occult blood testing (FOBT).
While the goal of Section 4104 of the ACA was to eliminate the coinsurance and deductibles for covered services, diagnostic or therapeutic colonoscopies have continued to be subject to coinsurance and deductible costs to beneficiaries.
To address this, the Biden Administration issued guidance[3] in January 2022 clarifying the patient cost-sharing for preventive benefits under the ACA. Under this guidance, a colonoscopy scheduled as a screening procedure per the USPSTF recommendations should not result in cost-sharing for items and services integral to performing the procedure, including polyp removal and pathology.
In addition, the guidance states that “follow-up colonoscopy is an integral part of the preventive screening without which the screening would not be complete.” Colonoscopies and related procedures scheduled and performed as a result a positive stool-based test, such as FIT, iFOBT, or mt-sDNA, should not result in cost-sharing.
Non-grandfathered plans under the ACA must implement this guidance for persons 45 and older for plan or policy years beginning on or after May 31, 2022. This guidance does not apply to traditional Medicaid programs except for those who may have coverage through Medicaid Expansion.
While this guidance also does not apply to Medicare[4] plans, Congress has passed the Removing Barriers to Colorectal Cancer Screening Act[5] in December 2020, which reduces cost-sharing for Medicare patients if polyps are found and removed during a screening colonoscopy. This bill is implemented in a phased approach, increasing the benefit by 5% every two years and eliminating all cost-sharing by 2030.
This new guidance will significantly reduce the cost of preventive services among Americans. However, it is important to verify coverage with the health insurance plan owner prior to scheduling any preventive services that may incur unexpected cost-sharing.
[1] Affordable Care Act (http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf)
[2] United States Preventive Services Taskforce Recommendation: Colorectal Cancer Screening (https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening)
[3] FAQs about Affordable Care Act Implementation Part 51 (https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf)
[4] Medicare coverage of Colonoscopies (https://www.medicare.gov/coverage/colonoscopies)
[5] Removing Barriers to Colorectal Cancer Screening Act (https://www.congress.gov/bill/116th-congress/house-bill/1570)