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Legislative Roundup

Monday, May 5, 2014

From the Patient Protection and Affordable Care Act (PPACA), federal research budget cuts, and grandfathered health plans to individual state actions regarding health care coverage, many issues have the potential to affect Preventing Colorectal Cancer’s mission: To educate the public and key stakeholders about the opportunities to reduce the incidence of colorectal cancer by promoting optimal screening and therapeutic care for patients and clinicians.

Federal Issues

Passage of the PPACA is advancing the purpose of Preventing Colorectal Cancer. Under the PPACA, non–grandfathered commercial insurance plans and self-insured health plans must cover colorectal cancer (CRC) screening with no cost-sharing for the patient. This is a huge win for those seeking to expand the screening rate. Another favorable outcome is the question whether health plans must cover polypectomies. The U.S. Department of Health and Human Services (HHS) has deemed that costs associated with such a procedure must be covered by a private insurance plan if the patient is receiving a preventive colonoscopy. This decision clarifies one of the more vexing issues that faced the industry and those seeking colonoscopies—how can a patient undergo a free screening but then be charged for a polypectomy?

While the mandated coverage for CRC screenings is a significant step forward, issues remain that affect our mission. While private health plans must cover screenings with no out-of-pocket costs, the same is not true of Medicare. Because of the large number of Americans on Medicare who undergo CRC screening each year, this is particularly relevant. There are bills in Congress to fix this problem. It remains to be seen whether these bills will advance since they must be paid for with cuts to other programs. We will continue to monitor this issue as it is a primary goal in 2014.

In addition to the colonoscopy-related bills, federal budget cuts have hit medical research and education particularly hard. Funding for cancer research programs at the National Institutes of Health (NIH) and the Department of Defense (DOD), as well as screening and education programs like the Colorectal Cancer Control Program, have seen steep cuts over the past two years. Recently, some funding was restored to the NIH and DOD, but their budgets remain significantly smaller than in past years, and certainly smaller than those in the field would prefer.

State Trends

Another issue relevant to PCC is the status of screening coverage for grandfathered health plans. While the ACA mandates coverage for CRC screening for “non-grandfathered health plans” (i.e. those in place before March 23, 2010), rules surrounding coverage for grandfathered plans are still governed by state law.

One of the trends we have seen in statehouses across the country is the move to mandate coverage for CRC screening (often with restrictions on cost-sharing) for these types of plans. There are currently 33 states that require insurers to cover at least some colorectal cancer tests.

Noteworthy Proposed Bills:

Congress (9 bills total relating to CRC):

H.R. 1070-Removing Barriers to Colorectal Cancer Screening Act of 2013 (Rep. Charles Dent introduced in the House on 3/12/13 and it has 46 cosponsors. No significant action has been taken in the House.)

The bill would waive coinsurance for colorectal cancer screening tests (thus covering 100% of their cost under Medicare Part B). While the Affordable Care Act requires that commercial non-grandfathered insurance cover colonoscopies with no cost-sharing, Medicare patients are subject to copays or coinsurance. This bill would eliminate that cost-sharing.

This bill has been sitting in committee since last spring. While action does not appear to be imminent, there are cosponsors from both parties. As with most issues like this, the cost is likely holding this back. If Congress finds a way to pay for this bill, it may move through both chambers.

H.R. 1320 and S. 608-The SCREEN Act (Rep. Richard Neal introduced in the House on 3/21/13 and Sen. Ben Cardin introduced in the Senate on 3/19/13 and it has no cosponsors. No significant action has been taken to move the bill forward.)

The bill would increase Medicare reimbursement for some cancer screening (including colonoscopies) by 10% for five years beginning in 2014. If 75% of Medicare beneficiaries who are recommended to receive screening get one, the program terminates. Providers who are eligible for the higher payment must participate in a quality improvement registry and the tests themselves must be done in accordance with outcomes-based quality measures.

The bill would also waive Medicare cost-sharing for colorectal cancer screenings, extend Medicare coverage to outpatient doctor visits that are done in conjunction with preparing or consulting regarding the screening.

H.R. 991-CT Colonography Screening for Colorectal Cancer Act of 2013 (Rep. Ralph Hall introduced the bill on 3/6/13 and it has 5 cosponsors. No significant action has been taken in the House.)

This bill would provide Medicare coverage for computed tomography colonography as a CRC screening test.

H.R. 2524-Medicare Better Health Rewards Program Act of 2013 (Rep. Erik Paulsen introduced the bill on 6/26/13 and it has three cosponsors). No significant action has been taken in the House.

S.Res. 41-A resolution supporting the designation of March 2013, as National Colorectal Cancer Awareness Month (Sen. Mike Enzi introduced the resolution on 2/25/13). It passed the Senate the same day. This type of bill passes the House and/or Senate on almost a yearly basis. It does not have the force of law but does provide recognition to the cause.

Randall H.H. Madry
Preventing Colorectal Cancer

Colonoscopy Screenings: Free to Patients?

Wednesday, April 30, 2014

Many patients struggle to understand the various rules relating to health care costs. As deductibles and overall patient liability rise, patients must work to determine the health care needs that are most important and work within their financial realities. But there’s good news on the colonoscopy front—screenings are most likely covered under your plan as a free service to patients, with insurance paying the bill!

The Patient Protection and Affordable Care Act (PPACA), which became effective January 1, 2011, requires commercial health care insurance plans to cover preventive services—without any cost sharing—for patients between the ages of 50 and 75. However, confusion remains since PPACA was passed. With the right information, most patients who fit the criteria for a screening colonoscopy may now get one with no out-of-pocket cost. Patients should always contact their insurance carrier prior to any procedure to verify benefits and potential costs, even if their provider does the same.

Some plans consider a colonoscopy for a patient with a personal history, and sometimes a family history, a diagnostic procedure rather than a screening, and therefore may not waive the patient financial responsibility. If the plan is out-of-network with the provider, benefits may not follow PPACA, which could result in cost to the patient. Self-funded plans or those that fall into a “grandfathered” status do not have to follow the PPACA guidelines. So there are many rules and loopholes for payers—it can leave patients scratching their heads wondering where they fit in.

The good news is that most plans do fall under the guidelines of PPACA. Patients between the ages of 50 and 75 who are due for a screening colonoscopy, and that have no other symptoms related to a need for a colonoscopy (e.g. rectal bleeding, abdominal pain), will most likely be covered with no patient financial responsibility. Regardless of the outcome of the screening procedure (e.g. biopsy, polyp removal), no additional cost should be allocated to the patient.

Insurance companies, while in the business of paying for health care services, look for ways to save money by passing on costs to the patients. Therefore, patients and providers should be vigilant in the insurance claims process and pay properly.

The best weapon—verification of benefits—happens before a patient steps into the surgery center for the procedure. It’s crucial the provider and patient have a common understanding of the purpose of the procedure. If a patient believes the procedure is scheduled as a screening, but the provider schedules the case with an understanding that there are symptoms, the mismatch will result in a different outcome than expected. While the physician must indicate any relevant symptoms for the procedure, the patient must then understand the financial implications, as this case would be considered diagnostic and not a screening.

However, effective communication between the physician and patient will help both parties understand the nature of the procedure. In the event a patient is left with a financial liability due to a screening procedure, the patient should contact both the provider and the insurance company. If benefits were verified in advance and the claim was submitted properly, there should be no surprises. Insurance companies process claims incorrectly every day, so patients and providers can and should fight incorrectly processed claims.

Medicare, unfortunately, does not follow the same guidelines as commercial payers. Medicare will pay a screening colonoscopy in full, with no patient cost, when the procedure does not result with a diagnostic maneuver, like a biopsy. In this case, the Medicare patient will have to pay 20% co-insurance, but if they have any deductible left for the year, that portion will be waived. However, Medicare deductibles are so small (less than $200/year), the patient most likely will be paying the same as a patient who was scheduled for a diagnostic procedure.

Ironically, this Medicare protocol may actually be costing the health care system more. There is simply no way for a patient or physician to know what they will do in the course of colonoscopy screening procedure. The point is to prevent colon cancer. But this fear of the unknown may actually be obstructing Medicare patients from being screened. A percentage of these unscreened Medicare patients will have cancer that will create higher costs to the health care system, as well as the obvious negative health consequences for the patients.

Overall, the steps being taken through PPACA and even CMS to promote colon cancer screenings is evidenced by the attempts to minimize cost implications for patients. The bottom line regarding coverage and liability is for patients and providers to verify and understand benefits for each specific case. Screening colonoscopies may save patients cash, and potentially their lives.

Stay tuned for the release of PCC’s next Issue Brief, which will look at health coverage updates and how the Affordable Care Act can improve colonoscopy screening rates. Visit www.PreventingColorectalCancer.org for updates.

 

Amy Fasti
Physician Endoscopy

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