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Colonoscopy cost sharing eliminated for privately insured patients

The federal government has issued an important clarification on preventive screening benefits under the Affordable Care Act. Patients with private insurance will no longer be liable for cost sharing when a pre-cancerous colon polyp is removed during screening colonoscopy. This ensures colorectal cancer screening is available to privately insured patients at no additional cost, as intended by the new healthcare law. Patients with Medicare coverage must still pay a coinsurance when a polyp is removed as a result of the screening colonoscopy.

Colonoscopy is a unique screening test because physicians are able to remove precancerous polyps and small cancers during the screening procedure. In many instances, removal of a polyp could result in the screening tests being categorized as a therapeutic procedure for which patients must pay coinsurance. This meant a patient could see their doctor for a screening colonoscopy assuming that it would be at no additional cost, only to receive a bill for the coinsurance after the doctor finds and removes a suspicious polyp. Cost sharing can create financial barriers that discourage the use of recommended preventive services.

Unfortunately, the cost-sharing issue remains a problem for patients with Medicare coverage. During National Colorectal Cancer Awareness Month we will continue to advocate for adoption of legislation that would waive the coinsurance for Medicare beneficiaries when a screening colonoscopy becomes therapeutic.

In May 2012, the American Cancer Society Cancer Action Network, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Fight Colorectal Cancer (FCC) and the National Colorectal Cancer Roundtable met with officials from the Department of Health and Human Services to discuss the cost-sharing problem. The groups advocated for the elimination of cost sharing for screening colonoscopy, and now we applaud the clarification the administration released earlier this week.

Following is the guidance language provided by the administration.

Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?

No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.


Contact: Aimee Frank
American Gastroenterological Association

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