Here’s one way Obamacare changed today

February 20, 2013

The department of Health and Human Services is out with another regulation for the Affordable Care Act, this one detailing the package of benefits that each insurance company must cover.

The final regulation looks similar to a draft published in November. It still allows states to pick between a handful of benchmark plans, so long as they cover a core set of physical and mental health benefits.

Policy analysts at the American Cancer Society Cancer Action Network did, however, notice a small—but important—update on how colonoscopies will be covered under Obamacare.

We've known all along that colonoscopies count as one of the preventive services that insurers must cover without copayment, as they are a screening recommended by the United States Preventive Services Task Force.

What we haven't known though, was what would happen if, during a colonoscopy, a doctor discovered a polyp and removed it. Would that still count as a screening—or would it cross the line into a treatment that the patient would need to pay for. Harris Meyer raised the issue back in April, writing for the Los Angeles Times:

If a patient with no symptoms goes in for a screening colonoscopy and the gastroenterologist finds no pre-cancerous or cancerous polyps, everyone agrees that Medicare and commercial insurers are required to cover the expensive test 100 percent. But when the doctor removes a polyp, some insurers apply charges– meaning the insurer pays less of the bill.

 

Critics say charging cost-sharing defeats the purpose of the law. Studies show that colonoscopies find a polyp in at least 25 percent of men and 15 percent of women. Thus, many people face financial "post-procedure shock," according to medical and consumer groups that are lobbying to stop insurers and Medicare from applying cost-sharing in this situation.

Follow up treatment for a polyp is a bit different than other conditions: Since the patient is typically sedated, there's little say in whether to move forward or not.

Today, the administration resolved this issue: It decided that insurance companies cannot charge patients for the removal of a polyp during a recommended colonoscopy. From an FAQ issued by the Department of Labor:

Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?
No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

There it is: Colonoscopy patients will not wake up to a surprise, post-operative bill.

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Neil Irwin · February 20, 2013