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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 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) recommendation. Are there other services performed in connection with a screening colonoscopy that must also be covered without cost-sharing?

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

  • required consultation before the screening procedure, if the attending provider determines that pre-procedure consultation would be medically appropriate for the individual;
  • anesthesia services, if the attending provider determines that anesthesia would be medically appropriate for the individual;
  • required preparation for the colonoscopy (e.g., bowel-preparation medications when medically appropriate and prescribed by a provider);
  • polyp removal during the colonoscopy; and
  • pathology exam on a polyp biopsy.

On the other hand, a 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 testing based on the findings of a screening colonoscopy.

For more information, see 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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