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

While many individuals have benefited from the new ACA rule to cover preventive health services and screening with no cost-sharing, there are cases where lack of clarity has meant that coverage does not work as expected. Consumer complaints about unexpected cost-sharing for colorectal cancer screening, in particular, have caught the attention of health plans, providers, regulators, and consumer advocates.Regulations to implement the ACA preventive care benefit specified a process for identifying services that would be subject to the no-cost-sharing rule, i.e., an “A” or “B” recommendation from USPSTF.   However, the case of cancer screening – and colorectal cancer screening in particular – illustrates that other factors may influence how insurers define covered preventive services. In particular inconsistent use of medical terminology continues to affect how providers and insurers describe screening procedures in certain circumstances or for certain patients. Provider coding practices and insurance claims processing systems don’t use consistent methods to identify procedures for which cost-sharing should be waived. As a result, insurers have not consistently applied the new ACA preventive care benefit to screening colonoscopy if a polyp is removed, if the procedure follows a positive FOBT, or if a person is at increased risk for such reasons as a family history.Some insurers have acted on their own to resolve the confusion by waiving cost-sharing for all colonoscopy procedures. According to medical directors, this approach fosters patient compliance with colorectal cancer screening recommendations and largely eliminates complaints by consumers and providers. This approach has the advantage of simplicity and promotes consistency of coverage for this preventive care benefit. Other approaches may also work, though not all insurers appear ready to change coverage and payment policies in the absence of further regulatory guidance. State regulators seem generally reluctant to offer guidance at this point and, in any case, do not have jurisdiction to clarify coverage for self-insured group health plans.As a standard for “defining” covered preventive services, the USPSTF review process distinguishes those preventive services that are evidence-based and a “good buy” for the general population. However, the USPSTF process typically does not address the nuances of these services, nor how they would be applied to groups at higher than average risk. Further, the USPSTF is not charged with developing recommendations on technical issues in insurance coverage or claims processing. Additional guidance is needed to crosswalk the USPSTF recommendations into more explicit rules for what health insurance policies must cover.The federal government could issue further guidance to improve clarity and make more consistent health insurance coverage of recommended cancer screening services. It could:

  • Provide additional specificity as to when consumers are eligible to receive cancer screening procedures with no cost-sharing. In the case of colorectal cancer screening, guidance could address whether cost-sharing should be waived when polyps are removed and when colonoscopy is provided as a follow up to a positive FOBT; for colorectal, breast, and other cancer screening procedures, guidance could also address whether cost-sharing should be waived when screening is provided to asymptomatic patients at higher risk.
  • Issue guidance to providers, health plans, and insurers on coding methods so that procedures are consistently identified and covered.
  • Coordinate with state insurance regulators and state Consumer Assistance Programs to collect complaints data, as well as data from insurers and group health plans, to monitor implementation of this benefit and recognize whether further adjustments may be necessary.

Stakeholders have raised the need for further guidance on implementation of other ACA preventive care benefits, as well, to clarify the definition of covered services, who should receive them, and when. For example, in response to recent USPSTF recommendations on the screening for and management of obesity in adults, representatives of health plans and insurers have raised questions about the specific services that must be covered. HHS reportedly is considering whether to issue additional guidance on how the ACA requirement applies for this benefit.1

In the absence of federal guidance, the new preventive care benefit may continue to be inconsistently applied for at least some procedures.

The authors thank the patients and officials of state insurance departments and consumer assistance programs, insurance companies, and medical provider practices who agreed to be interviewed for this report. The authors also gratefully acknowledge the following individuals who reviewed drafts of this report: Barry Berger, Joel Brill, Anjelica Davis, Lynda Flowers, Natalie Hamm, Djenaba Joseph, Mike Mizelle, Erin Reidy, Mona Shah, Kathleen Teixeira, and Ann Zauber. Finally the authors thank the following individuals who provided other research support for this project: Adriane Burke, Nathan Bush, Alissa Crispino, Diane Dwyer, Kate Allen Fox, Joanne Gersten, Andrew Spiegel, and Marylou Stinson.

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