Insurance coverage of colonoscopies to screen for colorectal cancer is a frequent source of frustration for consumers, including a reader who asks about his situation. In addition to his query, this week I also address questions about Medicare premiums and delays in determining Medicaid eligibility.
Q: When I had a screening colonoscopy in 2015, the doctor removed a polyp and told me to come back for another colonoscopy in three years. I paid nothing for the 2015 test because it was a preventive screening. When I scheduled my appointment for this year, the provider said the procedure was diagnostic because of that earlier polyp removal. Doesn’t the law protect people in these situations from being charged for more frequent but necessary screening?
Not necessarily. The Affordable Care Act greatly expanded coverage of preventive services, including requiring commercial insurers to cover screenings for colorectal cancer without charging patients anything out-of-pocket if they’re between ages 50 and 75. In general, screening colonoscopies for people at average risk are recommended every 10 years by the U.S. Preventive Services Task Force. (Under the law, preventive services are covered at no cost by insurers if they meet the task force’s recommendations.) There’s no charge to the patient for the test, even if a benign growth called a polyp is found and removed.
Doctors may recommend more frequent “surveillance” testing, as they did in your case, if during screening they find any polyps, which may put you at higher risk for colon cancer. Since the task force doesn’t have a recommendation for high-risk colorectal cancer screening, insurers aren’t required to cover it without cost sharing.
“Insurers will cover the test, but whether the patient is held harmless for the copay and deductible depends on the insurer,” said Dr. J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society.
Medicare also covers screening colonoscopies without charging beneficiaries anything out-of-pocket. The program covers tests every 10 years, and every two years if someone is considered high-risk. But there’s a catch: In contrast to private coverage, if a polyp is found during the test, that procedure is then considered diagnostic and patients will be subject to a copayment.
Q: I signed up for a plan on healthcare.gov last fall in Virginia after I lost my employer coverage and learned that my 16-year-old daughter might be eligible for Medicaid. Two months have passed, and we still don’t have an answer. I understand that her coverage will be retroactive back to the date we applied, but in the meantime, I have to pay any medical bills. The state says it has 45 days to make a decision, but we’re past that. What can I do?