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Can Our Plan Require Cost-Sharing for Colonoscopy-Related Services?



QUESTION: Our company sponsors a non-grandfathered group health plan subject to the Affordable Care Act’s preventive services mandate. We understand that the plan may not impose cost-sharing for a colonoscopy that is performed as a screening procedure under the United States Preventive Services Task Force (USPSTF) recommendations. What other colonoscopy-related services must be covered without cost-sharing?

ANSWER: Certain services performed in connection with a colonoscopy performed as a preventive screening procedure pursuant to the USPSTF recommendation must be covered without cost-sharing where the services are an integral part of the colonoscopy (subject to reasonable medical management). Examples include―

  • a required consultation before the colonoscopy if the attending provider deems it medically appropriate;
  • anesthesia services, if the attending provider deems it medically appropriate;
  • required colonoscopy preparation (e.g., bowel-preparation medications when medically appropriate and prescribed by a provider);
  • polyp removal during the colonoscopy; and
  • a pathology exam on a polyp biopsy.

Your plan must also cover, without cost-sharing, a follow-up colonoscopy conducted after a positive non-invasive stool-based test or direct visualization test (e.g., sigmoidoscopy or CT colonography). USPSTF recommendations state that the follow-up colonoscopy is an integral part of the preventive screening without which the screening would not be complete. On the other hand, the plan may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service. For instance, cost-sharing could be imposed for surveillance colonoscopies that are based on the findings of a screening colonoscopy.

For more information, see EBIA’s Health Care Reform manual at Section XII.C (“Coverage of Preventive Health Services”). See also EBIA’s Group Health Plan Mandates manual at Section XIV.C (“Required Preventive Health Services Coverage”) and EBIA’s Self-Insured Health Plans manual at Section XIII.C.1 (“Preventive Health Services”).

Contributing Editors: EBIA Staff.

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