Current Legislation

Legislative Spotlight: ACA Q&A Series

Over the next few months, Crawford Clay, CCA Patient Advocacy Coordinator, will be answering your questions about the Affordable Care Act (ACA) in this ongoing series. Email your question to cclay@ccalliance.org for a chance to be featured.

Q: I’ve heard that under the ACA, all colonoscopies should be covered by insurance. Is this true? – Robert Nicholas

A: In short, it depends on your answer to several questions:

1. Are you on a public health program like Medicare or Medicaid or on a private plan that started after September 23, 2010?
2. Is this a screening colonoscopy (meaning you have no symptoms and no personal or family history)?
3. Is your colonoscopy being performed by an in-network provider? ¹

If you answered yes to all of these questions, then your colonoscopy should be covered without copay. Keep in mind that your healthcare provider can choose to cover any screening test covered under the guidelines, including fecal occult blood (FOBT) tests, sigmoidoscopy and colonoscopy. ²

If it is a diagnostic colonoscopy (meaning you have symptoms or a personal or family history) then you might end up sharing the cost of the test with your insurer. Many insurers will waive the copay but still require the deductible. It is important to note that if you go in for a screening and they find a polyp, then your test changes from a screening to a diagnostic colonoscopy that you may need to pay for. Read more about coverage of colonoscopies under the ACA’s prevention benefit.

The Colon Cancer Alliance is currently working with other groups to eliminate this loophole through the Removing Barriers to Screening Act H.R. 4120.

Under the new law, most plans do not cover other costs associated with colonoscopies. You may have to pay for your own bowel prep and transportation to and from the colonoscopy. Be sure to check with your healthcare provider to see if there are any local resources to help offset these costs.

Furthermore, with the new law, each state will chooses its own benchmark plan. This plan will determine what insurance is required to cover in your state, which means that in the future, your state may choose not to have certain screening tests covered. This is part of the Essential Health Benefits discussion. Contact your state insurance commissioner, governor and legislator and make your voice heard and demand coverage.

¹ Healthcare.gov Fact Sheet
² Kaiser Family Foundation Fact Sheet

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