Diving in on HHS' Recent FAQs on Preventive Services

A few months ago, we blogged about a report that CHIR faculty co-authored—in collaboration with Kaiser Family Foundation, the American Cancer Society, and the National Colorectal Cancer Roundtable—exploring how private insurers are covering colorectal cancer screenings, a preventative service that is supposed to be covered without cost sharing under the Affordable Care Act (ACA).

In that report, we found that there was significant confusion about how and whether to apply cost-sharing for colorectal cancer screening. Specifically, we described the variation in how cost-sharing is applied and how providers code procedures in three different clinical circumstances: 1) when a polyp is detected and removed during a screening colonoscopy; 2) when a colonoscopy is performed following a positive stool blood test; and 3) when the individual is at increased risk for colorectal cancer and may receive earlier or more frequent screening compared with average risk adults.  This variation resulted in consumers facing unexpected cost sharing and—according to regulators in some states—generated more consumer complaints than any other ACA protection. We also found that state regulators were looking to the federal government for guidance on how to address this issue.

We are pleased to report that the federal government recently offered such guidance. In a set of Frequently Asked Questions (FAQs) released last week, federal regulators addressed one of the clinical circumstances that we explored in the report: whether insurers can apply cost-sharing when a polyp is removed during a screening colonoscopy.

What does the federal guidance say? According to Question 5 of the FAQs, insurers can no longer apply cost-sharing when a polyp is removed during a screening colonoscopy. Referencing the clinical guidelines of organizations such as the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, Question 5 noted that polyp removal is an “integral part of a colonoscopy” and, thus, insurers cannot impose cost-sharing if the polyp is removed during a screening procedure. However, federal regulators went on to note that cost-sharing can be imposed if the polyp is removed during a colonoscopy that is not a recommended preventive service.

What does the federal guidance mean? This FAQ is expected to provide additional protection for consumers by limiting the cost-sharing associated with screening colonoscopy. Thus, consumers should no longer fear that their scheduled screening colonoscopy will not be covered just because a polyp was detected and removed during the procedure. Yet, because the guidance allows cost-sharing to turn on whether a screening colonoscopy is considered to be (and accordingly coded as) “preventive” or “diagnostic,” consumers should consider asking their physician and insurer about how their procedure will be classified and why.

While the FAQ includes an important protection for consumers, it raises additional questions. First, what relief, if any, does the guidance provide for consumers that have already faced unexpected cost-sharing since the ACA went into effect in September 2010? Second, why was there such a delay in releasing guidance on an issue that has resulted in so many consumer complaints? Third, the guidance did not address the other clinical circumstances where cost-sharing rules are fuzzy: screening colonoscopy for high-risk individuals and following a positive stool blood test. Will additional guidance be forthcoming on these circumstances or will confusion continue for insurers, providers, and consumers? Finally, are federal regulators exploring the distinction between “preventive” and “diagnostic” in the context of other screening benefits under the ACA and how will future issues—such as cost-sharing for mammograms—be resolved in a clinically sound and timely manner?

CHIR plans to explore these questions and other related issues and promises to keep you posted our findings. Be sure to check in with CHIRblog for everything you need to know and, in the meantime, don’t be shy about sharing your thoughts!

The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.