2015-12-09 18:23:31 UTC

Coverage Update: Screening Colonoscopy Cost Sharing

Dec. 10, 2015

Confusion still exists about how the Medicare CRC screening benefit is covered and we've put together a quick summary of the latest updates to help clarify this.

AGA has long advocated that patients have access to colorectal cancer (CRC) screenings. Since the Medicare benefit was created for CRC screenings, patients have been educated and awareness has been raised about the benefits of and the need to screen a greater percentage of the population. However, confusion still exists about how this benefit is covered and we've put together a quick summary of the latest updates to help clarify this.


The Affordable Care Act (ACA) waives the Part B deductible for “colorectal screening tests regardless of the code billed for the establishment of a diagnosis as a result of the test, or the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as a screening test.”

  • However, the ACA did not specify a similar policy for the coinsurance when a Medicare beneficiary gets a screening colonoscopy that becomes therapeutic, so the beneficiary is on the hook for the coinsurance in that scenario. Despite the fact that AGA, our sister societies and the American Cancer Society have all pushed the administration to waive the coinsurance regardless of the outcome of the screening, CMS has stated that it does not have the authority to change the law, which it says would take an act of Congress.
  • CMS has also revised the definition of colorectal cancer screening tests to include anesthesia that is separately furnished in conjunction with screening colonoscopies. Effective Jan. 1, 2015, expenses incurred for a screening colonoscopy, and the anesthesia services furnished in conjunction with such tests, will not be subject to the Part B deductible and will not count toward meeting that deductible. The statutory waiver of deductible will apply to the anesthesia services furnished in conjunction with a colorectal cancer test even when a polyp or other tissue is removed during a colonoscopy. However, if a polyp or lesion is found during the screening colonoscopy, the beneficiary is responsible for the coinsurance for any covered anesthesia.  

Commercial Insurance

What adds to the confusion around the cost sharing problem are the differing policies for commercial plans under the ACA. A few years ago, the administration clarified that patients who have a screening colonoscopy that turns therapeutic should have their cost sharing waived since removal of polyps is integral to the screening. The administration issued frequently asked questions on the ACA’s preventive services, including two that specifically address issues associated with screening colonoscopy benefits for commercial health plans.

  • Effective Dec. 23, 2015, patients will no longer have cost-sharing responsibilities for a pre-procedure consultation before the colonoscopy and the pathology services required as part of the screening. Regarding the pre-procedure consultation, the administration clarified that cost sharing should not be imposed since the pre-procedure is “necessary to protect the health of the patient.” Cost-sharing should also be waived for the pathology services, as well, since “the pathology exam is critical for achieving the primary purpose of the colonoscopy screening.” 
  • AGA is pleased with this guidance and continues to advocate that a positive stool blood test should be defined as part of the screening continuum and therefore the subsequent colonoscopy should not be subject to cost-sharing. The guidance also does not clarify whether the prep for the procedure is covered. It’s important to note that this guidance does not apply to Medicare. 

AGA will continue to seek additional guidance on the preventive benefits to ensure that financial barriers are not causing patients to forgo lifesaving screenings. Join AGA in advocating for the enactment of H.R. 1220/S. 624, Removing Barriers to Colorectal Cancer Screening Act, which would fix the coinsurance problem under Medicare. We remain hopeful that as this legislation continues to garner bipartisan support and that it can be fixed in the 114th Congress once and for all.

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