Coverage of Colonoscopies Under the Affordable Care Act's Prevention Benefit
Introduction
Patient Protection and Affordable Care Act, P.L. 111-148, § 1001 (establishing § 2713 of the Public Health Service Act) (codified at 42 U.S.C. § 300gg-13 (2006)).
- The USPSTF is an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers. The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements." An A or B rating from USPSTF means that there is high certainty that the net benefit is moderate to substantial and that the USPSTF recommends the service.
Sommers BD, Wilson L. 2012. Fifty-Four Million Additional Americans are Receiving Preventive Services Without Cost-Sharing Under the Affordable Care Act. Issue Brief, Office of the Assistant Secretary for Planning and Evaluation (Feb. 15, 2012).
See for example, Solanki G, Schauffler HH, Miller LS. The direct and indirect effects of cost-sharing on the use of preventive services. Health Services Research 2000;34:1331-50. See also Wharam JF, Graves AJ, Landon BE, Zhang F, Soumerai SB, Ross-Degnan D. Two-year trends in colorectal cancer screening after switch to a high-deductible health plan. Med Care 2011;49:865-71. See also Trivedi AN, Rakowski W, Ayanian JZ. Effect of cost sharing on screening mammography in Medicare health plans. N Engl J Med 2008;358:375-83.Manning, Willard et al. (1988).
- This report does not explore how cost-sharing for preventive services is addressed in the Medicare program. See Appendix A for additional details on cost-sharing for colonoscopy in Medicare.
Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-37.
- 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. Patients might also face unexpected cost-sharing if they don’t realize they are covered under a grandfathered health plan.
Report
Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA: A Cancer Journal for Clinicians 2012;62:10-29.
A Snapshot of Colorectal Cancer. American Cancer Society, 2012. (Accessed July 1, 2012, at http://www.cancer.gov/aboutnci/servingpeople/snapshots/colorectal.pdf.)
Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA: A Cancer Journal for Clinicians 2008;58:130-60.
Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2012: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal for Clinicians 2012.
See for example Colonoscopy Costs and Pricing Information. 2012. (Accessed August 1, 2012, 2012, at colonoscopycosts.com.) See also How much does colonoscopy cost? 2008. (Accessed August 1, 2012, 2012, at health.costhelper.com/colonoscopy.html.) It is difficult to get precise charge and cost information related to colonoscopy because it is not standardized and reports are anecdotal. However, most published references are within and above the range described above. At Costhelper.com dozens of consumers have posted the charges and co—pays they incurred, with highly variable charges even when grouping procedures based upon normal exams vs. those with polypectomy.
McAbee K, Martinez E and Wolf H. Mining the Colorectal Cancer Screening Network to explore practices, policies, and challenges in colorectal cancer screening. Technical report submitted to National Colorectal Roundtable, funded by American Cancer Society and CDC (Cooperative Agreement Number U50/DP001863). October 2012.
Winawer SJ. Natural history of colorectal cancer. Am J Med 1999;106:3S-6S; discussion 50S-1S.
Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012;366:687-96.
Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993;329:1977-81.
Wolf HJ, Masias A. Cumulative Evaluation Report for the Colorado Colorectal Screening Program, June 1, 2006 – June 14, 2010. Project Deliverable for the Colorado Colorectal Screening Program Funded by the Cancer, Cardiovascular and Pulmonary Disease Grant program. Denver: Colorado Department of Public Health and Environment. 2010.
GI Quality Improvement Consortium Ltd. GIQuIC data registry: A joint initiative of the American College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE) In; 2012.
Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-37.
Smith RA and Mandel JS. Principles of Cancer Screening. In Rose MG, VT DeVita, TS Lawrence, SA Rosenberg (Eds.), Oncology for the Primary Care Provider. Philadelphia, PA: Lippincott, Williams and Wilkins, 2012 (in press)
American Medical Association. New CPT Modifier for Preventive Services. CPT® Assistant 2010;20:3-6.
- These recommendations do not apply to individuals with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) or those with inflammatory bowel disease.
Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-37.
Smith RA, Mandel JS. Principles of Cancer Screening. In Rose MG, DeVita VT, Lawrence TS, Rosenberg SA (eds.) Oncology for the Primary Care Clinician. Lippincott Williams & Wilkins, Philadelphia, 2012 (in press)
Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-37. note 23.
Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA: a cancer journal for clinicians 2008;58:130-60.
Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-37.
Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-37.note 23.
Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA: A Cancer Journal for Clinicians 2008;58:130-60.
Rex DK, Kahi CJ, Levin B, et al. Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer. CA: A Cancer Journal for Clinicians 2006;56:160-7; quiz 85-6.
Winawer SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. CA: a cancer journal for clinicians 2006;56:143-59; quiz 84-5.
- However, consumers may not always complain to state insurance regulators; staff at one large group gastroenterology practice in South Carolina reported receiving as many as 4-5 complaints daily on this issue.
CT Public Act No. 12-190 (2012).
- A self-insured group health plan (or a 'self-funded' plan as it is also called) is one in which the employer assumes the financial risk for providing health care benefits to its employees. Most self-insured health plans are regulated by the federal government under the Employment Retirement Income Security Act (ERISA). State insurance laws do not apply to self-insured health plans.
VT H.B. 601 (2012).
VA H.B. 705 (2012); VT H.B. 601 (2012).
ME Public Law No. 516 (2008).
Internal Revenue Service, Health Savings Accounts – Additional Qs&As, Notice 2004-50, Q&A 26 (Aug. 16, 2004).
- H.R. 4120, Removing Barriers to Colorectal Cancer Screening Act of 2012, introduced by Representative Charles Dent, R-PA, 3/1/2012.
Conclusion
Appendix
- See MLN Matters #SE0746, “Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy, at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0746.pdf