What You Need to Know About the New Federal Policy on Colonoscopy Coverage
Written by Melissa Schenkman, MPH, MSJ
Have you ever had a colonoscopy?
If your answer is “No, I’m too young for that,” you might be surprised to find out how much this life-saving test costs and how many “young” people have been diagnosed with colorectal cancer in their 20s, 30s, and 40s. You might also be surprised to find out that a colon polyp can take on average 10 years to become cancerous. So, while you may not be diagnosed until your 30s, your colon polyp may have formed and been growing since you were in your 20s.
However, for those like me, who have had a colonoscopy in their 30s, you might be left with some sticker shock when you get the bill for out-of-pocket costs, even when you have some form of health insurance.
That’s why we were so thrilled when our partners at the Colon Cancer Foundation shared with us the news of a new coverage policy for follow-up colonoscopies spearheaded by the organization, Fight Colorectal Cancer (Fight CRC), and their Catalyst State-by-State Advocacy Program.
Follow-up colonoscopies are now fully covered by insurance, but many are still seeing charges
According to estimates from the Centers for Disease Control and Prevention, if all people who were eligible for a screening got one, 68% of deaths from colorectal cancer could be avoided.
All the more reason that this new coverage policy is so important. It requires commercial insurers, Medicare and Medicaid to fully cover a follow-up colonoscopy when patients who are eligible for colorectal cancer screening do a non-invasive stool-based test (like a Fecal Immunochemical Testing (FIT Test) or a Cologuard) that comes back positive.
Who is eligible?
Adults who are 45 years old or older, of average risk, and do not have signs or symptoms of colorectal cancer. All important factors to know regardless of where you fall on the millennial age spectrum for two reasons:
First, we have relatives and friends who will be eligible for this coverage. For those of us who are also caregivers to older adults this policy could make a huge difference in access to screening.
Second, the age for first screening was lowered from 50 to 45 and is now covered by this follow-up coverage policy. Organizations like Fight CRC and Colon Cancer Foundation are continually working to improve access to colorectal cancer screenings and with the continued increase of colorectal cancer diagnoses in millennials, there is no question that one day this coverage and increased accessed will extend to even younger age groups.
The new federal policy is a huge win for patients, as the cost of colonoscopies are a barrier to people getting them and ultimately saving lives.
“This is something that had been on our radar for quite some time but took on an even greater sense of urgency during the COVID-19 pandemic. People were unable or unwilling to go in for a colonoscopy and we saw a significant drop off in colorectal cancer screening,” said Fight CRC’s Director of Advocacy, Molly McDonnell. “This policy was enacted after a sustained advocacy effort on behalf of the colorectal cancer community.
Molly McDonnell is the Director of Advocacy at Fight Colorectal Cancer, the leading patient advocacy group in colorectal cancer. The organization’s mission is as follows:
“We fight to cure colorectal cancer and serve as relentless champions of hope for all affected by this disease through informed patient support, impactful policy change, and breakthrough research endeavors.”
To turn the idea for this federal policy into reality, Fight CRC worked with the American Gastroenterological Association and the American Cancer Society Cancer Action Network to engage the Departments of Health and Human Services, Labor, and Treasury as well as the Centers for Medicare and Medicaid Services to urge them to issue guidance to ensure that most commercial plans and Medicare plans cover the follow-up colonoscopy without cost sharing for the patient.
“Fight CRC also worked at the state level through our Catalyst State-by-State Advocacy Program to enact legislation in several states removing out of pocket costs for follow-up colonoscopy. This helped set the stage for action at the federal level,” McDonnell said.
While we are fortunate to have multiple screening modalities for colorectal cancer, she pointed out, colonoscopy is seen as the gold standard.
“If a patient receives an abnormal result on a non-invasive screening test, they must get a colonoscopy to complete screening. Unfortunately, many patients faced and continue to face out of pocket costs with that follow-up colonoscopy that can prevent them from completely screening,” McDonnell said.
“We believe that this policy will help increase access to colorectal cancer screening by removing a significant cost barrier.”
The reduced costs also extend to reduced healthcare costs.
Colorectal cancer has the second highest treatment cost of any cancer and according to Fight CRC, the average per-patient costs for medical services when studied, were highest for the last year of life ($110,100), followed by the initial care phase ($66,500). So, early detection of colorectal cancer not only reduces the burden on us as patients, but also on our healthcare system as a whole.
Why is colonoscopy care so expensive?
Colonoscopies in the U.S. can range in price from $1,250 to $4,800 or more with researchers from a 2021 study finding the average cost of the procedure to be $2,125. The average out-of-pocket cost is $80. I can tell you from firsthand experience the out-of-pocket cost can be more than five times that, even if you have health insurance.
There are a few factors that impact your final cost for a colonoscopy. These include:
Having the procedure at an outpatient versus an inpatient facility
If your colonoscopy is considered a preventive health service (screening) versus a diagnostic procedure (having had polyps in the past 10 years, a positive stool-based test, signs and symptoms in your lower gastrointestinal tract)
Your healthcare providers being in-network versus out-of-network for your health insurance
Colonoscopy care is more expensive when you your colonoscopy is:
Performed at an inpatient facility
Considered a diagnostic procedure
Your gastroenterologist, anesthesia care team, or the lab any biopsies (or all three) are sent to are considered to be out-of-network providers by your health insurance.
Challenges to accessing colonoscopy care
The potential of these unknown out-of-pocket costs can even cause people to shy away from non-invasive screening tests to start because if they come back positive, they already know that a follow-up screening will be financially out of reach.
“We know that many patients have been hesitant to do non-invasive screening tests because of potential out of pocket costs and likewise some physicians have been hesitant to prescribe them to patients,” McDonnell said. “We hope this policy will help change that and help more people who may not want to get a colonoscopy at first to still get screened.”
In addition to the cost, there are other barriers to people accessing a colonoscopy screening test that you might not have realized:
A long wait time to get an appointment
Living in a part of the country with limited availability to certain types of healthcare
“There is a colonoscopy backlog in this country that can cause patients to wait six months or more to get a colonoscopy. Depending on where a patient lives, they also may not have easy access to a gastroenterologist who can perform a colonoscopy,” McDonnell said.
Free Policy Change Resources
Fight CRC has created multiple ways to educate the public about the key elements of this new coverage policy. For more information to share with your friends and family who having access to this coverage could make a difference for, visit these resources:
For patients and caregivers: Coverage for a Follow-up Colonoscopy
For healthcare providers and medical offices: Coverage for a Follow-up Colonoscopy
Conclusion
Despite the humongous victory the new federal policy is for the many people ages 45 and older, who are in need of a follow-up colonoscopy and screening in general, there is still much more work to be done for millennials and members of Generation Z when it comes to increasing our access to a colonoscopy.
Sadly, predictions are that by 2030 colorectal cancer will be the number one cancer killer for those 20-49. Thankfully, YMyHealth along with Fight CRC and the Colon Cancer Foundation are all working to combat the rise of colorectal cancer in young people.
At Fight CRC, the focus is on both patients and providers.
“Young patients are often misdiagnosed or not taken seriously by their doctor. Fight CRC is working to help educate physicians and the general public about the growing number of young people being diagnosed with colorectal cancer and the signs and symptoms that people should be aware of,” McDonnell said.
As our fight continues, we at YMyHealth urge you to do these three things:
Learn about your family history.
Find out if your parents or siblings have had colon polyps and if so, talk with your doctor about having a screening test—a non-invasive stool-based or a colonoscopy, if you haven’t had one.
Learn about the signs and symptoms of colorectal cancer.
(Here are some good places to start: How Young Onset Cancers Differ and Eleanor’s Story).
Check out the excellent resources from Fight CRC and the Colon Cancer Foundation to help you and your family stay healthy and educated about colorectal cancer.
For more information also visit the Colon Cancer Foundation’s Colorectal Cancer : Resources for Young Patients and Survivors*
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