Follow-up colonoscopies after abnormal stool test completely covered by insurance.
After years of calling our senators and representatives, knocking on doors, and advocating til blue in the face, the colon cancer community can report a victory for Americans everywhere! On Monday, January 10, federal guidelines for commercial insurance plans changed to cover follow-up colonoscopies after abnormal results from a CT colonography, sigmoidoscopy, or stool-based screenings (FIT, FOBT, Cologuard®).
Why is this a game-changer? Previously, visual and non-invasive stool-based screening were considered “preventive screening” by commercial insurance companies, and therefore covered by the Affordable Care Act. Non-invasive stool tests specifically are a terrific option for those at normal risk of colorectal cancer. They’re often preferred by those with busy schedules, since non-invasive tests don’t require the infamous “prep” associated with colonoscopies (and no time off from work to recover from the sedation, either!). Non-invasive stool tests are accurate, widely-available, easily distributed, and discreet. The more people who take them means the more colon cancer that can be detected early. So everybody wins!
Except… when these tests detected abnormalities – such as blood in the stool – and a follow-up colonoscopy was required. You guessed it: that colonoscopy was subject to co-pays and other cost sharing. This meant enormous financial barriers for patients, since uninsured colonoscopies run on average up to $3,000! Life-saving screening appointments were missed, cancelled, or never even scheduled.
But no more! From the Department of Labor guideline document issued Monday, January 10: “A plan or issuer must cover and may not impose cost sharing with respect to a colonoscopy conducted after a positive non-invasive stool-based screening test or direct visualization screening test for colorectal cancer for individuals[.]” Furthermore: “The follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization screening test is therefore required to be covered without cost sharing.”
In layman’s terms, that means a colonoscopy after a positive stool-based test or other visual screening is fully covered by insurance!
And wait, there’s more! The guidelines also state that the following must be covered without co-pay:
- Required specialist consultation prior to the screening procedure
- Bowel preparation medications prescribed for the screening procedure
- Anesthesia services performed in connection with a preventive colonoscopy
- Polyp removal performed during the screening procedure; and
- Any pathology exam on a polyp biopsy performed as part of the screening procedure.
This is tremendous news! These new guidelines put patients front and center, and makes life-saving screenings and procedures more accessible than ever before. Per this new guidance, These changes go into effect for plan or policy years beginning on or after May 31, 2022. Talk to your insurance company about what that means for you.
At this moment, there is no change for Medicare and Medicaid patients, but the work continues to close this loophole in that area as well.