A new report by the Kaiser Family Foundation, the American Cancer Society, and the National Colorectal Cancer Roundtable shows that not all consumers are receiving screening for colorectal cancer free of charge, as required by the Affordable Care Act (ACA). The report says depending on their provider, insurer, or state in which they live, consumers may face cost sharing, which could discourage screening.
Under the Affordable Care Act, insurers are required to cover recommended preventive services such as colonoscopies without any patient cost-sharing such as co-pays or deductibles. To find out if this was happening, the report, Coverage of Colonoscopies under the Affordable Care Act’s Prevention Benefit, examined current cost-sharing practices for colorectal screenings through interviews with experts and officials in the medical and insurance industries.
The report found insurers may interpret colonoscopy as treatment rather than preventive care. That’s because unlike most screening tests, colonoscopy not only detects signs of cancer, but also removes the polyps that pose the risk. And that happens in roughly half of procedures. The report says when polyps are removed, or when the patient being screened is at high risk for colon cancer, the colonoscopy is sometimes fully covered by insurers, but in some other cases patients are required to pay some or all of the costs for the procedure, depending on their health plan cost-sharing levels. Sometimes that’s because insurers consider the colonoscopy part of treatment; other times insurers intend to cover these colonoscopies under the preventive care benefit, but the wrong billing code is used, insurers won’t recognize the test as being preventative.
One reason the report was done: this issue may not be limited to colonoscopy. In fact, there’s evidence similar confusion is occurring with other procedures, such as mammograms, with some women being asked to help pay the costs simply because they’re at high risk, for example.
The report says additional clarification from the federal government could reduce coverage inconsistencies.