Understanding what is covered by your plan can be very complex. It can vary based on your insurer’s medical policy, your specific benefits, deductibles and amounts you may have already incurred against a deductible, and other factors. The best way to find out is to call your insurer directly, but here is some information as of March 2021 about major plans and relevant state laws:
- People with Medicare Part B1 may receive a bill for a follow-up colonoscopy that includes co-insurance (typically 20%) and the deductible.
- People with Medicare Advantage may receive a bill for a follow-up colonoscopy that includes co-insurance (in varying amounts, depending on the plan) and a deductible.
- According to their posted medical policies, UnitedHealthcare2, UPMC Health Plan3, BlueCross and BlueShield of Vermont4 and other payers generally cover a follow-up colonoscopy at no out-of-pocket cost to the patient.
- Kentucky5, Oregon6, Texas7, Rhode Island8, Arkansas9, and California10 have enacted state laws that require some plans in those states to cover follow-up colonoscopies at no out-of-pocket cost to the patient.
- Illinois11 enacted a state law that requires some plans to cover follow-up colonoscopies at no out-of-pocket cost to the patient. High-deductible health plans are excluded from this law and patients with a high-deductible plan may be subject to out-of-pocket costs for a follow-up colonoscopy.
The Affordable Care Act requires insurers to cover colon cancer screening at no cost to the patient. We believe that a follow-up colonoscopy after a positive screening result is part of the screening process, and it should also be covered at no cost to the patient. If you receive a bill for a follow-up colonoscopy, please call our Customer Care Center 24/7 at 1-844-870-8870 or visit our appeals page to create a customized letter to send to your insurance company.
1. MedicareSupplement.com. How do medicare copays and deductibles work? Updated February 18, 2021. Accessed March 14, 2021. https://www.medicaresupplement.com/content/medicare-copay 2. United Healthcare. Commercial Coverage Determination Guideline. Updated January 1, 2021. Accessed March 12, 2021. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/preventive-care-services.pdf 3. UPMC Health Plan. Provider Partner Update. Updated September 2020. Accessed March 12, 2020. https://upmc.widen.net/s/hdzkat0oc9 4. Blue Cross Blue Shield of Vermont. FIT Notice to GI and General Surgeons. Updated November 20, 2020. Accessed March 12, 2021. https://www.bcbsvt.com/sites/default/files/2020-11/FIT%20Notice%20to%20GI%20and%20General%20Surgeons%20FINAL.pdf 5. Kentucky General Assembly. Coverage under health benefit plan for colorectal cancer examinations and laboratory tests. Updated January 1, 2020. Accessed March 12, 2021. https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=49488 6. OregonLaws.org. Colorectal cancer screenings and laboratory tests. Accessed March 12, 2021. https://www.oregonlaws.org/ors/743A.124 7. Texas State Legislature. An act relating to health care benefit plan coverage for colorectal cancer early detection. Accessed June 10, 2021. https://legiscan.com/TX/text/SB1028/2021 8. Rhode Island State Legislature. The Maryellen Goodwin Colorectal Cancer Screening Act. Accessed June 6, 2021. http://webserver.rilin.state.ri.us/PublicLaws/law21/law21007.htm
9. Arkansas State Legislature. An act to amend the requirements for coverage for colorectal cancer screening; and for other purposes. Accessed June 10, 2021. https://www.arkleg.state.ar.us/Bills/FTPDocument?path=%2FBills%2F2021R%2FPublic%2FSB309.pdf 10. California State Legislature. An act to add Section 1367.668 to the Health and Safety Code, and to add Section 10123.207 to the Insurance Code, relating to health care coverage. Accessed November 3, 2021. https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202120220AB342 11. Illinois State Legislature. An Act concerning regulation. Accessed January 1, 2022. https://www.ilga.gov/legislation/fulltext.asp?DocName=&SessionId=110&GA=102&DocTypeId=HB&DocNum=2653&GAID=16&LegID=&SpecSess=&Session=