Craig Wilson, JD, MPA
Director, Health Policy
In a major win for state and federal advocacy efforts to reduce financial barriers for colorectal cancer screening, the Centers for Medicare and Medicaid Services has proposed that “a follow-up colonoscopy to an at-home test be considered a preventive service, which means that cost sharing would be waived for people with Medicare.”
The proposed change comes as part of the Calendar Year 2023 Physician Fee Schedule proposed rule, which also proposes that screening be covered for individuals ages 45 and above, consistent with United States Preventive Services Task Force (USPSTF) recommendations.
The change for the Medicare program follows policy efforts in multiple states, including Arkansas, to align with USPSTF recommendations to begin screening for people at average risk for colorectal cancer at 45 and clarify that follow-up colonoscopies are a part of the screening process for which cost sharing should not be required. Arkansas Act 779 of 2021 became effective this year, lowering the age for covered screenings to 45 and prohibiting cost sharing for follow-up colonoscopies for Arkansans in most individual and group insurance policies, including those covering Medicaid expansion beneficiaries and the state and public school employee health benefit plan.
In January of this year, the U.S. Department of Labor issued similar guidance, aligning with USPSTF age recommendations for screening and extending cost-sharing protections to Arkansans with coverage through federally regulated, self-funded plans and to individuals in states without a law such as the one passed in Arkansas.
ACHI partnered with Fight Colorectal Cancer last year to develop a report assessing the prevalence of colorectal cancer screening in Arkansas and identifying gaps in access to screening. The report showed that three out of five patients who had a follow-up colonoscopy — many of whom had coverage through Medicare — were exposed to cost sharing during the study period. The report was accompanied by an infographic providing context about the findings as well as an analytical blueprint for other states to execute similar analyses. ACHI Health Policy Director Craig Wilson presented findings from the report at Fight Colorectal Cancer’s Catalyst Program meeting in December 2021 and at the 6th Annual Southeastern Colorectal Cancer Consortium conference in June.
The proposed Medicare payment rule, which is expected to become final later this year after public comment, adds the single largest payer for healthcare services to the list of payers aligning with USPSTF recommendations and offering cost-sharing protection for follow-up colonoscopies. However, as these new requirements are implemented across all payers, beneficiary and provider education will be critical to ensure that optimal screening occurs and that patients are not inappropriately billed due to colonoscopies being coded as diagnostic versus screening.