Questions About Colon Screening Coverage Still Vex
Consumers; Difference for Medicare, Others
People in group, individual health plans don't pay
for polyp removal during a screening colonoscopy; feds say it is an
integral part of screening and should be covered without cost sharing -
Medicare may still require co-pay. Some remain vexed and confused about
testing that begins at age 50 for
second leading cancer killer
By Michelle Andrews, Insuring Your Health, KHN
April 16, 2013 - No one looks forward to screening tests for colon and
rectal cancers. But under the Affordable Care Act, patients are at least
supposed to save on out of-pocket costs for them. Coverage is not always
clear, however, and despite the federal government's clarifications,
some consumers remain vexed and confused.
Colorectal cancer is the second
leading cause of cancer death in the United States. Screening
can catch cancers earlier, and removing polyps discovered during a
colonoscopy can prevent cancer from developing in the first place.
force recommends colorectal cancer screening for most adults
starting at age 50. These tests include
colonoscopy (in which a doctor inserts a flexible tube with a
video camera at the end into the anus to examine the large intestine for
polyps, tumors and other abnormalities), sigmoidoscopy (a similar
process that examines only the lower part of the colon) and fecal occult
blood testing (which examines the stool for traces of blood).
A colonoscopy is the most thorough of the screening
tests and is favored by many clinicians. But about half the time, polyps
are discovered and removed during the test to determine whether they are
cancerous. This can create billing problems for patients, says Katie
Keith, a research professor at Georgetown University who co-authored a report on
screening colonoscopy coverage under the Affordable Care Act.
According to the study, some insurers judged that a
colonoscopy with polyp removal was a therapeutic rather than a screening
procedure, and subsequently billed patients for some or all of the
test's cost, depending on their coverage, which can reach $2,000,
In February, the Obama administration
stated that for people in group and individual health plans,
polyp removal during a screening colonoscopy was an integral part of the
screening test and should be covered without patient cost sharing.
Other screening coverage questions remain murky.
What happens, for example, if someone gets a positive result on a fecal
occult blood test? In that case, the task force says a colonoscopy is
required to examine the colon for polyps or other problems. But insurers
vary in whether they consider such a follow-up colonoscopy to be part of
the original screening process or a separate diagnostic test, according
to the report by Keith and others, including the Kaiser Family
Foundation. (Kaiser Health News is an editorially independent project of
Get regular screenings for
colorectal cancer: Medicare
Did you know colorectal cancer is the second
leading cause of cancer-related deaths in
the United States among cancers that affect
both men and women? If everyone 50 or older
got screened regularly, as many as 60% of
deaths from this cancer could be avoided.
In most cases, colorectal cancer develops
from precancerous polyps (abnormal growths)
in the colon or rectum. Fortunately,
screening tests can find these polyps, so
you can get them removed before they turn
into cancer. Screening tests also can find
colorectal cancer early, when treatment
It’s National Colorectal Cancer Awareness
Month – do what you can to reduce your risk
for colorectal cancer. If you’re 50 or
older, or have a personal or family history
of colorectal issues, make sure you get
screened for colorectal cancer regularly.
Don’t worry about the cost—Medicare covers a
variety of colorectal
cancer screenings, and you pay nothing
for most tests.
"In many communities, stool testing may be common
because people can't get an appointment for a colonoscopy for months,"
says Robert Smith, senior director of cancer screening at the American
Cancer Society, another co-author of the report. "If they have a
positive stool test, now they face the uncertainty of what it would cost
to get the colonoscopy."
Another gray area emerges when people are at higher
risk for colon cancer because of family history or their own history of
polyps. In these cases, patients are often advised to get a colonoscopy
more often than every 10 years, the recommended frequency for people at
average risk. In February, the federal government
clarified that high-risk patients could qualify for more
frequent screening without cost sharing.
Despite this, some patients have run into coverage
Because doctors discovered three polyps during a
colonoscopy five years ago, Allen Worob, 66, is considered at high risk
for colon cancer. Worob's physician advised him to get another
colonoscopy in five years. At first, Worob's insurer told him that the
procedure would cost him nothing if no polyps were found but that he'd
owe the full $2,500 charge if a polyp was discovered. (Worob's primary
coverage is through his wife's group health plan, supplemented by
After more discussions with his insurer, Worob, who
lives in Rochester, N.Y., was told the procedure would be covered
without any out-of-pocket charge whether or not any polyps were found.
But Worob didn't want to take any chances. He decided to wait for a
letter from his insurer spelling that out before getting the test.
"Just because [the government] has clarified the
law, it doesn't mean anybody's going to follow it," he says. "I can't
take a $2,500 hit."
Despite the administration's explanations,
questions remain, says Susan Pisano, a spokeswoman for America's Health
Insurance Plans, a trade group.
"The [Department of Health and Human Services] has
issued clarifications on some scenarios related to colonoscopy
screening, but other questions are being raised and we may need to ask
for further clarification," she says.