Coverage of Colonoscopies Under the Affordable Care Act's Prevention Benefit

The Affordable Care Act (ACA) requires private health insurers to cover recommended preventive services without any patient cost-sharing, such as copays and deductibles.1 The ACA requires coverage of services with an “A” or “B” recommendation from the United States Preventive Services Task Force (USPSTF), an independent panel of clinicians and scientists.2 Recommended services include screening for diabetes, obesity, cholesterol, and various cancers including colorectal cancer, as well as counseling for drug and tobacco use and healthy eating, among others. This requirement took effect for new plans sold or renewed on or after September 23, 2010. An estimated 54 million Americans received expanded coverage of preventive services under the ACA in 2011.3

Although many factors affect use of preventive services, out-of-pocket costs are a barrier to seeking recommended screening tests, counseling, and immunizations. An extensive body of research shows that individuals—including the insured—are less likely to seek health services when they have to pay out-of-pocket costs.4 By eliminating cost-sharing, the ACA has tried to remove barriers to important preventive services. Yet, there are reports that many asymptomatic adults undergoing screening for cancer have been billed for services they expected would be covered under the ACA’s provision that eliminates cost sharing for A- and B-rated preventive services.

This report explores how private insurers5 are approaching cost-sharing for colorectal cancer screening, which received an “A” rating from the USPSTF.6 Patients can encounter unexpected cost-sharing for screening colonoscopy under three different clinical circumstances: 1) when a polyp is detected and removed during a screening colonoscopy; 2) when a colonoscopy is performed as part of a two-step screening process following a positive stool blood test; and 3) when the individual is at increased risk for colorectal cancer and may receive earlier or more frequent screening compared with average risk adults.7 To explore this issue, interviews were conducted with a variety of stakeholders and regulatory officials familiar with the implementation of this new benefit. Based on their reports, it appears that, under all three scenarios, there is significant variation in whether insured consumers receive colorectal cancer screening with no cost-sharing. Those interviewed reported that they had received complaints from consumers who faced unexpected cost-sharing for screening colonoscopy. Some indicated that cost-sharing for a screening colonoscopy has generated the most complaints of any of the ACA’s new consumer protections.



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