On April 20th, the Federal Government provided important guidance for private group plans participating in health exchanges set up via the ACA (Patient Protection and Affordable Care Act). The Departments of Labor as well as Health and Human Services provide ongoing coverage and patient cost-sharing guidance for these plans. The latest installment impacts our GI patient cost-sharing for bowel preparation:
Q1: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, can a plan or issuer impose cost sharing for the bowel preparation medications prescribed for the procedure?
No. Consistent with a previous FAQ, the required preparation for a preventive screening colonoscopy is an integral part of the procedure. Bowel preparation medications, when medically appropriate and prescribed by a health care provider, are an integral part of the preventive screening colonoscopy, and therefore, are required to be covered in accordance with the requirements of PHS Act section 2713 and its implementing regulations (that is, without cost sharing, subject to reasonable medical management).
Please note that this guidance does not include Medicaid or Medicare.
ACG will continue to update members on insurance exchange coverage issues impacting members and our patients. ACG remains disappointed that the Federal Government requires private plans to waive cost-sharing during the continuum of colorectal cancer screening on one hand, but believes it does not have the regulatory authority to do so in Medicare. This inconsistency in policy was specifically discussed last week during the ACG Governors’ Washington D.C. Congressional Fly-in, when educating Congress on the importance of the SCREEN Act (H.R.2035/S.1079), as well as the Removing Barriers to Colorectal Cancer Screening legislation (H.R.1220/S.624).
Whitfield L. Knapple, MD, FACG
Chair, ACG National Affairs Committee