Updated Cost-Sharing Guidance for Medicare Beneficiaries

Jonathan Gardner, Data Manager

Medicare’s Calendar Year 2023 Physician Fee Schedule final rule[ii], published November 1, 2022, contains some positive changes around colorectal cancer screening in support of the Biden Administration’s Cancer Moonshot program.[iii]

One of the goals addressed by this final rule is to reduce barriers and expand coverage for colon cancer screening. With this change, Medicare has reduced the minimum age for colorectal cancer screening from 50 to 45 years to align with the recommendations by the United States Preventive Services Task Force.[iv]

In addition, the definition of colorectal cancer screening has been expanded to include a follow-on screening colonoscopy after a positive result of a non-invasive test, such as a Fecal Immunochemical Test (FIT) or multi-targeted stool DNA test (mt-sDNA). In most cases, this means there will be no applicable beneficiary cost sharing for the non-invasive test nor the follow-on colonoscopy screening test.

However, when the follow-on screening colonoscopy requires additional procedures during the same clinical encounter, the phased-in Medicare payment percentages for colorectal cancer screening services described in the Removing Barriers to Colorectal Cancer Screening Act[v] will apply. Medicare will cover those services at 85% through 2026, then 90% through 2029, and 100% beginning 2030 and thereafter.

This important change is a big step towards early detection of colorectal cancer. The Centers for Medicare & Medicaid Services now recognizes that a positive stool test without a follow-on colonoscopy is not a complete screening. As always, it is important to verify coverage with the health insurance plan owner prior to scheduling any services that may incur unexpected cost-sharing.

CMS-1770-F Revisions to Payment Policies under the Medicare Physician Fee Schedule Quality Payment Program and Other Revisions to Part B for CY 2023 (https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1770-f)

[ii]Federal Register 87 FR 69404 (https://www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other)

[iii]Cancer Moonshot (https://www.whitehouse.gov/cancermoonshot/)

[iv]United States Preventive Services Taskforce Recommendation: Colorectal Cancer Screening (https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening)

[v]Removing Barriers to Colorectal Cancer Screening Act (https://www.congress.gov/bill/116th-congress/house-bill/1570)