The Importance of Waiving Cost-sharing for Follow-up Colonoscopies: Action Steps for Health Plans

The Affordable Care Act (ACA) eliminates cost-sharing for United States Preventive Services Task Force (USPSTF) – recommended preventative services for individuals who are privately insured, including screening for colorectal cancer by high sensitivity stool test or colonoscopy for adults ages 50 and 75.* Some health plans, however, apply cost-sharing to colonoscopies that follow a positive stool test. This creates a financial incentive for patients to select the more costly and invasive colonoscopy as their initial test. Additionally, this cost-sharing creates a financial disincentive that may lead patients to forego the follow-up test that they need.

This Issue Brief gives an overview of this issue and makes a request to health plans to waive cost-sharing for members when colonoscopy is ordered as follow-up to a positive stool test or other colorectal cancer screening test, just as cost-sharing is waived for colonoscopy when it is selected as the first-line screening exam.

Learn more in Colorectal Cancer Screening Best Practices Handbook for Health Plans, a compilation of best practices, case studies, templates and tools.

*The ACA preventive services requirements do not apply to “grandfathered” health plans that were in existence prior to March 23, 2010, as long as such plans continue to meet certain standards for grandfathered plans.

Coverage of Colonoscopy Under the Affordable Care Act’s Prevention Benefit

The Affordable Care Act (ACA) requires private health insurers to cover recommended preventive services such as colonoscopies without any patient cost-sharing. This 2012 report finds that confusion over whether colorectal cancer screenings are characterized as preventive care or treatment means patients sometimes receive unexpected bills for the procedure. The report examines cost-sharing practices for colorectal screenings through interviews with experts and officials in the medical and insurance industries.

This report was co-authored by The Kaiser Family Foundation, the American Cancer Society, and NCCRT.

Report on Savings to Medicare from Increased Colorectal Cancer Screening (2007)

This report describes potential savings to Medicare and pre-Medicare payers from increased colorectal cancer screening among 50-64 year olds.

The Lewin Group, in collaboration with the NCCRT, developed a cost model that explores how increased colorectal cancer screening among pre-Medicare eligible individuals (aged 50-64 years) could translate into Medicare savings realized through earlier detection and treatment, specifically polypectomy and treatment of early stage cancer. The study also looked at net costs to pre-Medicare payers.

CRC Screening Network Practice and Policy Survey

The aim of the Colorectal Cancer Screening Network Practice and Policy survey was to gather information from members of the National Colorectal Cancer Screening Network and their contacts about practices and policies and challenges associated with colorectal cancer screening delivery. The survey and report were commissioned by the NCCRT and conducted by the Colorado School of Public Health.

This Network was chosen to serve as the survey population due to the geographic distribution of its members and its composition of public health professionals working within the field.

The two components of the project are:

• Exploring issues around medical providers and access to medical care; and

• Exploring issues around state and local practices and policies related to insurance and colorectal screening.

Portions of the survey were informed by the NCCRT Policy Action Task Group Strategy Session of March 2011.  Many thanks to those of you who came to that meeting and took the time to help us discuss and prioritize key issues.