Colorectal Cancer Prevention and Early Detection

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Colorectal cancer screening – state and federal coverage laws

The benefits of early detection colorectal cancer screening

Screening can find non-cancerous colorectal polyps and remove them before they become cancerous. If colorectal cancer does occur, early detection and treatment dramatically increase chances of survival.

The relative 5-year survival rate for colorectal cancer when diagnosed at an early stage before it has spread is about 90%. But only about 4 out of 10 colorectal cancers are found at that early stage. Once the cancer has spread to nearby organs or lymph nodes, the 5-year relative survival rate goes down to 70%, and if cancer has spread to distant organs (like the liver or lung) the rate is about 13%.

(A standard 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed; it includes people with colorectal cancer who may die of other causes, such as heart disease. Five-year relative survival rates assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This is a better way to see the impact of the cancer on survival.)

Not only does colorectal cancer screening save lives, but it also is cost effective. Studies have shown that the cost-effectiveness of colorectal screening is consistent with many other kinds of preventive services and is lower than some common interventions. It is much less expensive to remove a polyp during screening than to try to treat advanced colorectal cancer. With sharp cost increases possible as new treatments become standards of care, screening is likely to become even more cost effective.

What is needed to increase the use of colorectal cancer screening?

Several colorectal cancer screening tests are available, but only about half of people aged 50 and older have them. Some factors affecting their use could include lack of public and health professional awareness of screening tools, financial barriers, and inadequate health insurance coverage and/or benefits.

The American Cancer Society believes that all people should benefit from cancer screenings, without regard to health insurance coverage. Limitations on covered benefits should not block your ability to benefit from early detection of cancer. To that end, the Society supports policies that give all people access to and coverage of early detection screening for cancer. Such policies should be age - and risk-appropriate and based on current scientific evidence as outlined in the American Cancer Society's early detection guidelines.

Federal law

Coverage of colorectal cancer screening tests is required by the Affordable Care Act (ACA), but the ACA doesn’t apply to health plans that were in place before it was passed (so-called “grandfathered plans”). You can find out your insurance plan’s grandfathered status by contacting your health insurance company or your employer’s human resources department. If your plan started on or after September 23, 2010, it’s required to cover colonoscopies and other colorectal cancer screening tests. If a plan started before September 23, 2010, it may still have coverage requirements from state laws, which vary, and other federal laws.

State activity

A number of states, as well as the District of Columbia, have passed laws requiring insurance coverage for a full range of colorectal cancer screening tests. A few other states require coverage of only certain tests or have agreements (instead of laws) among insurers to provide coverage for a full range of tests. Still other states have no laws regarding coverage.

Note that state laws can’t require coverage from insurance plans that are self-funded by the employer. (Self-funded or self-insured plans are those in which the employer pays the health care costs, even though they often contract with an insurance company to keep records and pay claims.) Only federal laws can affect self-funded plans. (See the “Federal law” section above.) You can find out if your health plan is self-funded by contacting your insurance administrator at work or reading your Summary of Plan Benefits.

States that have screening laws that ensure coverage for a full range of tests*:

  • Alaska
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • Georgia
  • Hawaii
  • Illinois
  • Indiana
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Missouri
  • Nebraska
  • Nevada
  • New Jersey
  • New Mexico
  • North Carolina
  • Oregon
  • Rhode Island
  • Texas
  • Virginia
  • Washington
  • Washington, D.C.
  • West Virginia
  • Vermont

States that have screening laws that require insurers to cover some but not all tests, or where insurers have voluntarily agreed to cover a full range of tests*:

  • Kansas
  • Minnesota
  • New York
  • Oklahoma
  • Pennsylvania
  • Wyoming
*Laws on coverage may vary slightly from state to state, so check with your insurer or your state government to see what is covered. Note that state laws don’t affect self-funded health plans.

In all other states, either there are no laws requiring insurance coverage, or there are laws that require insurers to offer (not necessarily provide) coverage.

Coverage by private health insurance

The Affordable Care Act requires coverage of colorectal cancer screening tests by health plans that started on or after September 23, 2010 (see “Federal law” section). Although many private insurance plans cover the costs for colonoscopy as a screening test, patients may be charged for some services. You may have to pay part of the costs of anesthesia, bowel prep kit, pathology costs, and a facility fee (where the procedure is performed). Patients should review their health insurance plan for specific details including if the doctor is within their insurance company’s list of “in-network” providers. If the doctor is not considered in the plan’s network, the patient may face significantly higher cost-sharing.

Colonoscopies that are done to evaluate specific problems, such as intestinal bleeding or anemia, are usually classified as diagnostic – and not screening – procedures. If that’s the case, you may have to pay any required deductible and copay. The same is true if the colonoscopy was done after a positive stool test (such as the FOBT or FIT) or an abnormal barium enema or colonography.

Before you get a screening colonoscopy, ask your insurance company how much you should expect to pay for the exam. This can help you avoid surprise costs. If you’re hit with large bills afterward, you may be able to appeal the insurance company’s decision. See Health Insurance and Financial Assistance for the Patient with Cancer for more information on this process.

Medicare coverage for colorectal cancer screening

Medicare covers an initial preventive physical exam for all new Medicare beneficiaries that must occur within one year of enrolling in Medicare. The “Welcome to Medicare” physical includes referrals for preventive services already covered under Medicare, including colon cancer screening tests.

If you've had Medicare Part B for longer than 12 months, a yearly “wellness” visit is covered without any cost. This visit is help to develop or update a personalized prevention help plan to prevent disease and disability. Your provider should discuss with you a screening schedule (like a checklist) for preventive services you should have, including colon cancer screening.

What colorectal cancer screening tests does Medicare cover?

Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year for all Medicare beneficiaries 50 years and older

Flexible sigmoidoscopy: Every 4 years for those 50 years and older, but not within 10 years of a previous colonoscopy

Colonoscopy

  • Every 2 years for those at high risk (regardless of age)
  • Every 10 years for those who are at average risk
  • 4 years after a flexible sigmoidoscopy

Double-contrast barium enema (DCBE) as an alternative if a doctor determines that its screening value is equal to or better than flexible sigmoidoscopy or colonoscopy:

  • Once every 2 years for those at high risk and are 50 years and older
  • Once every 4 years for those 50 years and older who are at average risk

At this time, Medicare does not cover the cost of virtual colonoscopy or stool DNA tests. Coverage under private insurance varies, but many follow Medicare rules. If you have questions about your costs, including deductibles or co-pays, it is best to speak with your insurance company.

What would a Medicare beneficiary expect to pay for a colorectal cancer screening test?

  • FOBT/FIT: Covered at no cost* for those age 50 years or older (no co-insurance or Part B deductible).
  • Flexible sigmoidoscopy: Covered at no cost* for those age 50 or older (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. If the test results in the biopsy or removal of a growth, it is no longer a “screening” test, and you will be charged co-insurance and/or a co-pay (although your deductible is waived).
  • Colonoscopy: Covered at no cost* at any age (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. If the test results in the biopsy or removal of a growth it is no longer a “screening” test, and you will be charged co-insurance and/or a co-pay (although you still don’t have to pay the deductible).
  • DCBE: Beneficiary pays 20% of the Medicare approved amount for the doctor services. If the test is done in an outpatient hospital department or ambulatory surgical center, the beneficiary also pays the hospital co-payment.

If you’re getting a screening colonoscopy, be sure to find out how much you will have to pay for the exam. This can help you avoid surprise costs. Patients may still have to pay for the bowel or colon prep kit, anesthesia or sedation, pathology costs, and facility fee. Patients may receive one or more bills for different elements of the procedure from different practices and hospital providers. Colonoscopies that are done to evaluate specific problems, such as intestinal bleeding or anemia, are not classified by Medicare as screening procedures. You may have to pay the usual deductible and copay required.

*This service is covered at no cost as long as the doctor accepts assignment (the amount Medicare pays as the full payment). Doctors that do not accept assignment are required to tell you up front.

Medicaid coverage for colorectal cancer screening

States are authorized to cover colorectal screening under their Medicaid programs. Unlike Medicare, however, there is no federal assurance that all state Medicaid programs must cover colorectal cancer screening in people without symptoms. Medicaid coverage for colorectal cancer screening varies by state. Some states cover fecal occult blood testing (FOBT), others cover colorectal cancer screening if a doctor determines the test to be medically necessary, and in some states, coverage varies according to which Medicaid managed care plan a person is enrolled in.


Last Medical Review: 08/05/2013
Last Revised: 06/06/2014