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Insured Patients Protected From Cost-Sharing for Follow-Up Colonoscopies, Department of Labor Clarifies

January 20, 2022

Author

Craig Wilson, JD, MPA
Director, Health Policy
501-526-2244
cwilson@achi.net

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New guidance from the U.S. Department of Labor (DOL) ensures that individuals in employer-sponsored or individual market health plans will be protected from cost-sharing for completion of colorectal cancer screening through a colonoscopy after a positive screen from a non-invasive, stool-based test or direct visualization. DOL included the guidance in an FAQ issued Jan. 10 that also delineated a requirement that insurers pay for at-home COVID testing.

The DOL guidance offers much-needed clarity to patients, providers, and insurers about whether a follow-up colonoscopy after a positive screen or direct visualization should be considered a continuation of preventive screening or a diagnostic colonoscopy. The guidance confirms that the follow-up colonoscopy should be considered a continuation of preventive screening, thus requiring insurers to both cover the colonoscopy and protect patients from cost-sharing in accordance with requirements in the Affordable Care Act (ACA).

The U.S. Preventive Services Task Force (USPSTF) identifies evidence-based preventive screenings and rates them, with ”A” and “B” recommended services falling within the ACA requirement for coverage and cost-sharing protection. In 2021, the USPSTF updated the recommendation for colorectal screening and extended the recommended age of screening to include people ages 45 to 49. The previous recommendation included only ages 50 to 75. In its practice considerations accompanying the recommendation, the USPSTF emphasized that “positive results on stool-based screening tests require follow-up with colonoscopy for the screening benefits to be achieved.”

The DOL guidance follows enactment of a law by the Arkansas General Assembly last year that requires private insurers regulated by the state to follow the USPSTF guidance to cover colorectal cancer screening for those ages 45 to 75 and offer the same cost-sharing protection for patients needing to complete screening with a follow-up colonoscopy. The DOL guidance extends that protection to Arkansans with coverage through self-funded plans that are federally regulated and to individuals in states that do not have a law such as the one passed in Arkansas last year.

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 were exposed to cost-sharing during the study period.