Colorectal Cancer News

Cost Sharing and Colorectal Cancer Screening

The Affordable Care Act requires that Medicare and private plans provide all US Preventive Services Task Force (USPSTF) recommended preventative services with no cost sharing, including screening tests (like colonoscopies) for colorectal cancer.

As a recent report by the Kaiser Family Foundation, the American Cancer Society and the National Colorectal Cancer Roundtable shows, this consumer protection is not being experienced equally by all consumers with private health plans. A consumer may or may not face cost sharing for a screening colonoscopy, depending on the provider they use, the insurer that administers their plan, or the state in which they live.

• Consumers in new plans are surprised to find that they don’t always get screening colonoscopy free of cost sharing as stipulated under the law. This is particularly concerning since cost sharing has been shown to deter use of proven life-saving preventive services. While not the subject of the recent report, there have been similar reports about the Medicare program as well.
  

• Consumers in new plans are complaining to states, insurers and providers. In some states, this issue has generated the largest number of consumer complaints out of all the early market reforms.
  

• There are three circumstances when consumers might face cost sharing for a screening colonoscopy. A consumer might face cost sharing when:
  1. A polyp is identified and removed or a biopsy is taken during a screening colonoscopy, despite the fact that removal of precancerous polyps is key to preventing colon cancer. Importantly, in half of all screenings, a screening colonoscopy results in polyp removal or biopsy.
     
  2. Following a positive stool-based test done for screening purposes, an enrollee has a follow-up colonoscopy as recommended by screening guidelines. The enrollee then faces cost sharing for the follow-up colonoscopy, even if no polyp is found.
     
  3. A patient undergoes routine screening colonoscopy at an earlier age than is typically recommended because they are at increased risk for colon cancer (for example, due to a family history of polyps or colon cancer.) In such cases, these patients – for whom routine colonoscopy is especially important – may face cost sharing for the procedure.
  4. The USPSTF recommendations indicate that the above circumstances are integral to the screening process.

• Why is cost sharing applied to screening colonoscopy in these situations? Depending on the circumstances:
  
  1. Healthcare providers vary significantly on how they code the procedure.
  2. Insurers vary significantly on how they apply the no cost sharing rule and how they interpret health care provider coding
  3. States appear to be taking different regulatory positions on this issue, but overall seem very reluctant to get ahead of HHS on the matter.
• The issue is not limited to colonoscopy. For example, women who are seeking routine mammography when they have a personal history or a family history of breast cancer or breast abnormalities may face similar problems with cost sharing.

• Cost sharing creates financial barriers, which could discourage the use of colonoscopy. Approximately 40 percent of U.S. adults age 50 and older have never been screened, despite the fact that evidence-based early detection tests can reduce the number of deaths from colorectal cancer by half.

• Consumers, advocacy groups, states and insurers are all looking to HHS for guidance to help ensure that all consumers with private insurance benefit equally from the law.

• H. R. 4120, the Removing Barriers to Colorectal Cancer Screening Act of 2012, introduced by Rep. Charlie Dent, waives the coinsurance in Medicare for a screening colonoscopy regardless of whether a polyp or lesion is found. Under current Medicare policy, the beneficiary deductible is waived regardless of whether a polyp or lesion is found. If this legislation passes, hopefully commercial payers will follow suit and there will be a consistent policy for all patients.

Read the full report: Coverage of Colonoscopies Under the Affordable Care Act’s Prevention Benefit

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