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 12%.

(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 mandated by the Affordable Care Act, but that doesn’t apply to health plans that were in place before it was passed. Those plans are covered by 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 among insurers (instead of laws) to provide coverage for a full range of tests. Still others require that insurance for testing be offered or available through Medicare Supplemental Insurance (Medigap) policies or have no laws regarding coverage.

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.

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.

Medicare coverage

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.

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 coinsurance or Part B deductible).
• Flexible sigmoidoscopy: Covered at no cost* for those age 50 or older (no coinsurance, copayment, 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 coinsurance and/or a co-pay (although your deductible is waived).
• Colonoscopy: Covered at no cost* at any age (no coinsurance, copayment, 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 coinsurance and/or a co-pay (although your deductible is waived).
• 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.

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

Medicaid

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.