Colonoscopy is on the U.S. Preventive Services Task Force's recommended list, with an A rating, for all adults 50 and older. It checks for colorectal cancer, which is preventable with screening and highly treatable if caught early. A National Institutes of Health report last year said cost sharing likely affects people's willingness to have such screening.
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.
"We raised this with insurers and they wouldn't budge," said Dr. David Johnson, past president of the American College of Gastroenterology. Since the law took effect, "it's still an ongoing problem," he added.
Medicare is waiving the deductible for its beneficiaries but charges patients a copay of $186 plus 20 percent of the doctor's fee, according to a Medicare spokeswoman. She said there have been few complaints from beneficiaries about the policy.
In addition to Kaiser Permanente and Health Net, Regence BlueShield, which has 3 million enrollees in four Northwest states, initially said it charged members the deductible and coinsurance if a colonoscopy found and removed a polyp. But Regence spokeswoman Rachelle Cunningham subsequently said that was a mistake, there should be no cost sharing charges, and the company was "re-evaluating and re-processing some claims."
A Health Net spokeswoman said that in an effort to help enrollees understand the situation, her company has trained its customer service staff to better explain colonoscopy coverage. Kaiser Permanente officials said the insurer "strongly supports" the health law's guarantee of preventive services but when "services extend beyond preventive and require diagnostic or therapeutic services" the cost sharing will apply, depending on the specific plan details. (KHN is not affiliated with Kaiser Permanente.)
Aetna, Cigna, Group Health Cooperative, Humana, United Healthcare and Wellpoint/Anthem all said members pay no cost-sharing when a polyp is found. Assurant refused to comment.
Kaiser Health News is an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan healthcare policy research organization. Neither Kaiser Health News nor the foundation is affiliated with Kaiser Permanente.
For the record: An earlier version of this story incorrectly stated that Dr. Virginia Moyer is a professor at Baylor University.