CHA Blog

• 16May

  CHA Opposes Adding Cost-Sharing for Office Visits Under Medigap Plans C & F

  Health Care Reform, Supplementing Medicare No Comments

  Below is a letter that Bonnie Burns, our Training and Policy Specialist sent to the National Association of Insurance Commissioners (NAIC) voicing CHA’s opposition to a proposal for adding a copayment under Medigap Plans C and F for Part B physician office visits. Burns is part of an NAIC subgroup that has been given the task of adding nominal copays to Medigap Plans C and F as a way to encourage “appropriate use” of physician services.

   

  Deputy Commissioner Michelle Robleto,

  Chair, NAIC PPACA Subgroup

  Florida Office of Insurance Regulation

  200 E. Gaines Street, Suite 121

  Tallahassee, FL 32399-0326

   

  Jane Sung, NAIC Senior Health Policy Analyst and Counsel

  444 North Capitol Street, N.W., Suite 701

  Washington, DC 20001

   

  Dear Deputy Commissioner Robleto:

  California Health Advocates (CHA) is an independent, non-profit consumer group that provides education and advocacy on behalf of California’s Medicare beneficiaries.  I represent CHA as a funded consumer representative to the NAIC and am an appointed consumer group member of the Medigap PPACA (B) Subgroup.

  The subgroup has been discussing adding ways to add nominal cost sharing to Medigap plans C and F that will encourage the “appropriate use” of physician services under Part B of Medicare as specified in the Patient Protection and Affordable Care Act (PPACA).  Adding a copayment for office visits under Part B is one option the subgroup has discussed, and one that I have consistently opposed.

   

  Cost sharing puts a financial barrier between the sickest beneficiaries and their doctor

  Our organization firmly believes that applying copayments to office visits is a blunt instrument affecting sick people to a far greater degree than those who are not yet sick.  Copayments create a financial barrier likely to cause Medicare beneficiaries to delay or go without necessary care from their physicians.   Cost sharing by definition shifts cost to beneficiaries who use medical services, and clearly imposes the highest costs on people with chronic illnesses who use the most services.  This effect is well known in Medicaid where certain populations like infants are protected from cost sharing mechanisms to ensure that vulnerable populations receive medical and preventive care without restriction.^[1]

   

  Cost Sharing Cannot “Encourage Appropriate Use” of Physician Services

  The subgroup has not seen any studies that support copayments as a means of encouraging or discouraging the use of appropriate medical services.  In fact, some studies have shown that cost sharing methodology that reduces costs in one sector of health care is likely to increase costs in another.^[2] Examples of that dynamic include people “pill splitting” or reducing their daily dosage of expensive medications leading to other health care costs later, or cost sharing that reduces outpatient use and later results in higher inpatient costs. ^[3]

  The subgroup has also heard from CMS and others of the impossibility of applying various amounts of cost sharing to particular types of office visits or other physician ordered medical services due to the complex nature of Medicare coding and reimbursement methods used to pay for these services.

   

  Medicare beneficiaries already pay high out-of-pocket costs

  It’s important to understand that Medicare beneficiaries pay Medicare Part B and D premiums, the cost of additional coverage such as retiree benefits, Medigap or Medicare Advantage, cost sharing for prescription drugs, and other expenses that are not covered by Medicare at all such as dental, vision, hearing, and long-term care.

  Half of all beneficiaries with annual incomes of about $22,000 spent at least $3,138 in out-of-pocket costs for their health care expenses.^[4] About 10 percent of all beneficiaries spent as much as $7,861 on their health care.  Additional front end costs in the form of copayments for office visits will add yet another amount to the costs beneficiaries already pay from fixed incomes.

   

  Existing cost sharing Medigap plans

  Only one Medigap benefit package, Plan F, eliminates all cost sharing.  The remaining standardized plans all impose some amount of cost sharing that Medicare beneficiaries over the years have largely shunned in an effort to protect themselves from large, unpredictable and unlimited amounts of medical costs.

  Medigap Plan F, and Plan C that doesn’t cover excess charges, are the two most preferred Medigap plans by beneficiaries precisely because those plans provide predictable coverage for their Medicare covered expenses.  Both plans also provide a predictable cost each month that can be budgeted against existing income.  Most Medicare beneficiaries cannot afford large unpredictable medical expenses.  When those unpredictable costs occur it frequently means tapping existing assets to pay for them, and that in turn may reduce any earning capacity of those assets.

   

  Conclusion

  The NAIC has been asked to perform a nearly impossible feat, i.e., to determine an amount of nominal cost sharing based on peer reviewed studies that can be added to Medigap Plans C and F that will in turn result in more appropriate use of physician services.  The impetus for this task is based on a viewpoint that the mere fact of owning a retiree or Medigap plan causes over utilization of Medicare outpatient services.  No study yet presented to the subgroup has been able to connect higher utilization of Medicare covered services with care that was not medically necessary.  As one study notes, the effect of supplemental insurance cannot be clearly distinguished from unobserved personal characteristics associated with higher medical spending^.[5]

  We disagree with the contention that the mere presence of supplemental benefits whether those are retiree, Medigap, or TriCARE for Life benefits, causes the inappropriate use of Medicare covered outpatient services.  We continue to oppose adding cost sharing to office visits, and to question whether it is even possible to meet the specific set of tasks the legislation requires.

  We appreciate the opportunity to add our comments to this important discussion.

  Sincerely,

  Bonnie Burns, NAIC Consumer Representative

  California Health Advocates

  ---

  [1] Leighton and Wachino, “The Effect of Increased Cost-Sharing in Medicaid” Center on Budget and Policy Priorities, July 7, 2005

  [2] Chandra A, Gruber J, McKnight R. “Patient Cost-Sharing and Hospitalization Offsets in the Elderly.” American Economic Review, vol. 100, no. 1, 2010.

  [3] Wong et al.; American Journal of Public Health, November 2001, Vol.  91, No. 11, Increased Ambulatory Care Copayments and Hospitalizations among the Elderly.

  [4] Lind, Keith D., JD, MS; Setting the Record Straight about Medicare, AARP Public Policy Institute.

  [5] Cost sharing effects on spending and outcomes, Schwartz, Katherine, Ph.D., Robert Wood Johnson Research Synthesis Report No. 20, December 2010

   

• 21Mar

  Celebrating 2 Years of Health Care Reform: Successes, Challenges & More Good to Come

  Health Care Reform No Comments

  Two years ago in March, President Barack Obama signed into law a historic piece of health care reform, the Affordable Care Act of 2010 (ACA). Since then, despite the heated political debates, much action and transformation in the health care arena has taken place, especially in California.

  Some of the statewide changes include setting up a health care “Exchange” to provide low-cost health insurance to millions more people by 2014. Policymakers are currently choosing the “essential” benefits to be covered in these plans. Another change is setting up Accountable Care Organizations (ACOs) to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients across various health care settings. The idea is to reduce costs and increase wellness. ACOs that lower their growth in costs while meeting performance standards on quality of care and putting patients first will be rewarded through Medicare’s Shared Savings Program.

  The state is also preparing to shift 1.2 million beneficiaries with Medi-Cal fee-for-service coverage into Medi-Cal managed care. This process has met some significant challenges in ensuring/guaranteeing that beneficiaries experience a seamless transition in their access to providers, treatment and medication, and hence may be delayed or slowed.

  Some other health care reform induced changes in California that are highlighted in a recent report by Health Access (PDF) include:

  • About 8,600 Californians with pre-existing medical conditions have gained access to affordable health insurance. Patients who have illnesses such as cancer or multiple sclerosis – who face high costs or denials on the open market – can buy insurance through the program.
  • More than 350,000 young adults have been able to stay on their parents’ health insurance plans until they are 26.
  • More than 370,000 low-income people have been covered by an expansion of Medi-Cal, the health insurer for low-income Californians, that is part of the state’s “bridge to reform” waiver to alter the state-federal program.

  And, in addition, Medicare beneficiaries across the state and the country are experiencing numerous specific benefits from health reform, including:

  • Many new and continued Medicare preventive benefits, mostly at no cost. Some of these include: an annual wellness visit, cancer screenings, smoking cessation counseling, and obesity screening and counseling.
  • Lower out-of-pocket Part D prescription drug costs for people with large medication expenses. Beneficiaries who reach the coverage gap (also known as the donut hole) now only pay 50% of their brand name drug costs and 86% of their generic costs versus 100%. This amount will decrease gradually until 2020 when beneficiaries will just pay 25% of their drug costs. The gradual closing of the coverage gap has resulted in over $171 million of savings to beneficiaries, according Health Access’ recent report (PDF).
  • An end to wasteful overpayments to Medicare Advantage (MA) plans, saving both taxpayers and the Medicare program millions of dollars. By 2014, MA plans will be required to invest at least 85% of all the funds they collect in premiums and copayments back into quality health care services for beneficiaries versus high administrative costs and profits.

  Currently, the health care reform law is only partially implemented. If and when it is allowed to be fully implemented, virtually all Americans will have access to affordable health care coverage. Also, our health care system will run more efficiently and effectively, ensuring quality of care for all residents and reversing the trend of skyrocketing health care costs. Health care reform benefits all, beneficiaries, families, young adults, children and our communities. Let’s keep it going!

• 24Feb

  Documentary Film Shows How Good Health Care Can Be Available to All at a Fraction of the Cost

  Health Care Reform No Comments

  Have you seen the documentary film, The Good News in American Medicine? You may think that statement is a contradiction in itself, BUT this 52 minute film interviews groups of innovative doctors and clinics around the country that are successfully demonstrating effective ways to provide quality health care to all their local residents at a fraction of the cost of neighboring communities. This film exposes the strategies, generosity, leadership and out-of-the box thinking used by these various communities across the nation.

• 13Feb

  President’s Budget Proposal Holds Several Medicare Cost Changes for New Beneficiaries

  Health Care Reform, Medicare basics No Comments

  We recently got word on the President’s budget proposal which contains some significant Medicare changes. Below are some excerpts regarding these changes, including: higher income-related premiums under Medicare Parts B and D, a new Part B premium surcharge for new beneficiaries who purchase first dollar coverage with a Medigap plan, a modified Part B deductible for new beneficiaries, and a home health care copayment for new beneficiaries.

  • Increase Income-Related Premiums Under Medicare Parts B and D (from from the budget for fiscal year 2013,  pages 34-35). Under Medicare Parts B and D, certain beneficiaries pay higher premiums as a result of their higher levels of income. Beginning in 2017, the Administration proposes to increase income-related premiums under Medicare Parts B and D by 15% and maintain the income thresholds associated with income-related premiums until 25% of beneficiaries under Parts B and D are subject to these premiums. This will help improve the financial stability of the Medicare program by reducing the Federal subsidy of Medicare costs for those beneficiaries who can most afford them. This proposal will save approximately $28 billion over 10 years.

  • Introduce a Part B Premium Surcharge for New Beneficiaries That Purchase Near First-Dollar Medigap Coverage (from page 35). Medigap policies sold by private insurance companies provide beneficiaries additional support for covering healthcare costs by covering most or all of the cost sharing Medicare requires. This protection, however, gives individuals less incentive to consider the costs of health care services and thus raises Medicare costs and Part B premiums. Of particular concern are Medigap plans that cover substantially all Medicare copayments, including even the modest copayments for routine care that most beneficiaries can afford to pay out of pocket. To encourage more efficient health care choices, the Administration proposes a Part B premium surcharge equivalent to about 15% of the average Medigap premium (or about 30% of the Part B premium) for new beneficiaries that purchase Medigap policies with particularly low cost-sharing requirements, starting in 2017. Current beneficiaries and near-retirees would not be subject to the surcharge. Other Medigap plans would be exempt from this requirement while still providing beneficiaries options for protection against high out-of-pocket costs. This proposal will save approximately $2.5 billion over 10 years.

  • Modify Part B Deductible for New Beneficiaries. Beneficiaries who are enrolled in Medicare Part B are required to pay an annual deductible. This deductible helps to share responsibility for payment of Medicare services between Medicare and beneficiaries. To strengthen program financing and encourage beneficiaries to seek high-value health care services, the Administration proposes to apply a $25 increase in the Part B deductible in 2017, 2019, and 2021 for new beneficiaries. Current beneficiaries or near retirees would not be subject to the revised deductible. This proposal will save approximately $2 billion over 10 years.

  • Encourages Beneficiaries to Seek High- Value Services (from page 112). The Budget includes structural changes that will help encourage Medicare beneficiaries to seek high-value health care services. To help improve the financial stability of the Medicare program, the Budget reduces the Federal subsidy of Medicare costs for those beneficiaries who can most afford them, and also introduces a modified Part B deductible for new beneficiaries beginning in 2017. To encourage ap propriate use of home health services that are not preceded by inpatient care, new beneficiaries beginning in 2017 would be responsible for a modest copayment for home health services in certain cases. Research indicates that beneficiaries with Medigap plans that provide first dollar or near-first dollar coverage have less incentive to consider the costs of health care services, thus raising Medicare costs and Part B premiums for all beneficiaries. The Budget applies a premium surcharge for new beneficiaries beginning in 2017 if they choose such Medigap coverage. In addition, it strengthens the Independent Payment Advisory Board to reduce long-term drivers of Medicare cost growth.

  • Introduce Home Health Copayments for New Beneficiaries. Medicare beneficiaries currently do not make copayments for Medicare home health services. This proposal would create a home health copayment of $100 per home health episode, applicable for episodes with five or more visits not preceded by a hospital or other inpatient post-acute care stay. This would apply to new beneficiaries beginning in 2017. This proposal is consistent with a MedPAC recommendation to establish a per episode copayment. MedPAC noted that “beneficiaries without a prior hospitalization account for a rising share of episodes” and that “adding beneficiary cost sharing for home health care could be an additional mea­sure to encourage appropriate use of home health services.” This proposal will save approximately $350 million over 10 years.

• 06Feb

  Pharmacies Must Notify Beneficiaries of Their Part D Appeal Rights ~ New Rule in Effect

  Health Care Reform, Medicare appeals, Prescription drugs No Comments

  As of January 1st of this year, all beneficiaries who are denied coverage for a drug are entitled to receive a standardized written notice from the pharmacy explaining their Part D appeal rights.  This change is due to the Affordable Care Act (ACA). Prior to this year, pharmacies could either hand out this information or just post a notice in the pharmacy without specifically alerting an affected beneficiary to their appeal rights. In addition, prior to this year none of these appeals rights forms were standardized. The new rule from the ACA requires pharmacies to use a new standardized form, Medicare Prescription Drug Coverage and Your Rights (instructions and form can be downloaded here). A Spanish version will also be posted soon.

  This requirement and standardized form is an important change for beneficiaries in terms of them being aware of and accessing their Part D appeal rights. Currently, the way the Part D appeals system is set up, the appeals process is NOT triggered when a beneficiary cannot obtain their drugs at a pharmacy. Nothing will happen unless the beneficiary proactively takes action and requests a “coverage determination” or “exception.” Only once an adverse coverage determination is initiated will the appeals process begin. (See our Part D appeals section for more info). Therefore, making sure each beneficiary who cannot get his/her drugs knows about their rights and HOW to start the appeals process is imperative to them having full access to their entitled benefits.

  Questions regarding this new standardized notice can be sent to PartD_Appeals@cms.hhs.gov.

  Additional information including frequently asked questions are included in the Centers for Medicare and Medicaid Services (CMS) memorandum sent out to all Part D sponsors entitled Revised Standardized Pharmacy Notice (CMS Form – 10147) (PDF).

• 18Nov

  NAIC Highlights Serious Concerns on Proposed Medigap Changes

  Health Care Reform, Supplementing Medicare No Comments

  Currently, there are multiple proposals in Congress, the Super Committee and the Administration, all of which will limit how much Medigap insurance will be able to pay in benefits as a way to address the current deficit. The thinking is that beneficiaries who don’t have enough “skin in the game,” i.e. beneficiaries who have supplemental coverage and don’t pay deductibles and copayments, end up using too many services, thus costing the Medicare program too much money. While there are no studies to support this thinking, and while the thinking doesn’t make sense, as Medicare will only cover those services it deems as reasonable and “medically necessary” anyway, the proposals are written as if this thinking is the truth.

  Some of these proposals would apply retroactively, regardless of the serious legal issues this poses, and would prevent the payment of benefits people already have in Medigap plans (i.e. benefits that cover the Part A and B deductibles, coinsurance and copayments).  The National Association of Insurance Commissioners (NAIC) recently released a Discussion Draft reflecting the views of regulators, industry and consumer groups about the dangers of eliminating existing benefits and prohibiting Medigap plans from paying a newly proposed Medicare deductible and half of the copayments.

  These proposals are not limited to Medigap. Congress is also trying to apply these prohibitions on benefits to retiree plans and to TriCare for Life.  Few Medicare beneficiaries know this is happening. We will be posting an article on these proposals and our views as an organization on them.

  Tags: budget cuts, deficit, Medicare reform, Medigap

• 16Nov

  Supreme Court to Review Constitutionality of New Health Care Law & Key Provisions

  Health Care Reform No Comments

  On Monday, the U.S. Supreme Court announced that it will review the legal challenges against the federal health reform law, the Affordable Care Act (ACA), in early spring 2012. While several different lawsuits challenging the law were presented to the justices, the court will only review the multistate lawsuit filed by 26 states and the National Federation of Independent Business.

  Although the ACA provisions that affect Medicare have not been challenged, the discord over the law casts uncertainty over the stability of new Medicare benefits and beneficiary protections provided by the new law.  The issues the Supreme Court will consider are:

  • Whether the controversial individual mandate is severable from the rest of the law or if the whole law, including the Medicare provisions, must be overturned if one provision is found unconstitutional;
  • Whether Congress may require states to expand their Medicaid programs by withholding funds from states if they do not;
  • Whether Congress was acting within its power to require Americans to buy health insurance or pay a penalty; and
  • Whether parties have legal standing to challenge the individual mandate requiring health coverage since that provision is not yet in effect.

  “Many Medicare beneficiaries have already benefited from the Medicare provisions in the ACA,” said Elaine Wong Eakin, Executive Director of California Health Advocates.  “These new Medicare benefits were hard-won, and it would be a shame to lose them should the Supreme Court find the whole law unconstitutional because of one provision.”  The Medicare improvements include discounts for beneficiaries in the Part D prescription drug “donut hole,” better access to preventive services, and an annual out-of-pocket cap for beneficiaries in Medicare Advantage plans.  Furthermore, the ACA incorporated cost-savings to sustain the Medicare program, and these cost-savings would be lost should the whole law be overturned.

  Even if the Supreme Court upholds the ACA, the Medicare program is targeted for cuts.  “As lawmakers find ways to cut the federal deficit, they should pay more attention to the cost-saving measures in the ACA,” recommended Wong Eakin.  The ACA introduced initiatives to control costs as well as improve care that results in better health outcomes for the population.  Instead of focusing on cutting Medicare benefits and increasing beneficiary out-of-pocket costs, lawmakers should build on the ACA initiatives.

  For more information on the health reform law, see our newsletter and other blog articles on this topic, including those listed below:

  • 50% Discount on Part D Brand Name Drugs Continues for 2012; 14% Discount on Generics
  • What Does Health Reform Mean for Medicare Beneficiaries? Summary of Key Provisions
  • Learn How Health Care Reform May Affect You in 2011
  • Health Reform Gives Some Immediate Benefits for Californians

  Tags: beneficiaries, health care reform, Medicare, Medicare Advantage

• 19Sep

  6 Short Videos Discuss Affordable Care Act Changes Coming in 2014

  Health Care Reform No Comments

  The California HealthCare Foundation (CHCF) has put together a series of 6 short, under 5-minute videos on what changes to expect from the Affordable Care Act in the next 2 years.

  Some highlights of the changes happening by 2014 include:

  • Government-funded health insurance (Medi-Cal) will expand to cover 2 to 3 million more Californians who can’t afford their own insurance today.
  • No one will be able to be denied coverage by an insurance company for having preexisting conditions, or for any other reason.
  • All Americans will be required to have health coverage, either through their work, through a public program, or by buying it on their own.
  • Businesses will have to offer adequate coverage to their employees or pay a penalty if those workers end up using government-supported coverage. Small employers with mostly low-wage workers will be eligible for subsidies.
  • State health insurance exchanges will help consumers shop for policies. Exchanges will help people learn if they are eligible for government-supported health care (like Medi-Cal) or subsidies to help pay for private coverage.

  Watch the 6 short videos on the CHCFwebsite. The videos include:

  1. An Overview
  2. Insurance Market Reforms
  3. Medicaid Expansion
  4. New Employer Responsibilities
  5. New Individual Responsibilities
  6. Health Insurance Exchange

  See our Health Care Reform section for information on how health reform affects Medicare.

• 30Aug

  Medigap Cost-Sharing Changes Meet Diverse Opposition

  Health Care Reform, Supplementing Medicare No Comments

  A provision in the 2010 federal health care reform law calls for changes in Medigap policies that essentially shift the burden of health care costs more onto the hands of beneficiaries. Several members in Congress have come to the unsubstantiated conclusion that because some Medigap plans (the most popular ones, C and F) cover most of the costs Medicare doesn’t — hence this insurance is referred to as MediGAP, beneficiaries use more services than they need. Therefore, they claim that Medicare pays more health care costs for these beneficiaries than others. To to help reduce these costs and hence the federal deficit, Congress has asked the National Association of Insurance Commissioners (NAIC) to propose changes to these Medigap plans so that beneficiaries pay more out-of-pocket for their health care.  The Congressional Budget Office estimated in March that such changes could save the government $53 billion in Medicare spending over a decade by strengthening incentives “for more prudent use of medical services.”

  Yet despite this request, as written in the health care reform law, an unlikely group of health insurance regulators, insurers and consumer advocates are raising opposition to these Medigap changes. In several interviews with reporters, Bonnie Burns, our Training and Policy Specialist who also serves on the NAIC, points out some substantial flaws or blind spots in Congress’ thinking. First, she strongly questions the idea that beneficiaries need an incentive not to use services. After all, physicians are the ones who order services, not the beneficiaries. Also, although some studies have found that seniors with Medigap policies use more Medicare services, they may be sicker than the average Medicare beneficiary, which is why they bought Medigap coverage in the first place.

  “To suggest that Medicare beneficiaries overutilize services on a whim because they don’t have ‘skin in the game,’ is pretty disturbing,” says Burns, as quoted in a recent article on Kaiser Health News.

  Second, Mary Beth Senkewicz, Florida’s deputy insurance commissioner, who chairs the NAIC’s senior issues committee, which includes the Medigap group, questions the legality of making changes that apply to Medigap policies beneficiaries have already purchased. The policies are contracts between the insurer and the beneficiary which contain certain promises of coverage. When state regulators require changes in insurance, those typically apply to future policies only, not to existing ones as well.

  Similar to Burns’ point of Medicare beneficiaries not being directly responsible for their higher health costs noted above, several members of this group have also suggested that Medigap policies are not responsible for Medicare’s growing costs. These carriers, the Medigap plans, only pay for services that Medicare deems to be medically necessary. Those determinations are not made by the Medigap insurance company.

  In Conclusion

  Some of Congress’ proposed Medigap changes dramatically shift costs onto seniors, leaving members of diverse interest groups concerned for good reasons. Medigap insurance has long been a product that has worked well for many benficiaires, currently 7 million, which comprise about 1/6 of the population with Original Medicare. These policies have helped maintain beneficiaries’ peace of mind, knowing that they have coverage for the gaps in Medicare. Putting this coverage in jeapordy may not be the best or even a mediocre move to help save some money to help the federal budget deficit, especially when savings aren’t even a guaranteed outcome.

  For more information on this issue, see the following articles:

  • Changes to Medigap Plans Meet Resistance
  • Lawmakers Propose Cuts to Medicare and Medigap Coverage
• 09Aug

  Clarifying “Free” Screening Colonoscopies for Medicare Patients

  Health Care Reform, Medicare basics No Comments

  I’m re-posting this article by Maria Selor. She’s the Supervising Attorney at the Elder Law Center in Wisconsin and wrote this article early this summer…

  On Jan. 1, 2011, the preventative services provision of the Affordable Care Act was extended, making all Medicare patients eligible for free, important preventive services – including colonoscopies. However, not all colonoscopies are created equal, and this could impact whether it is truly without cost to you. This article explains what you should be aware of when receiving this important and life-saving test.

  Screening Colonoscopy vs. Diagnostic Colonoscopy
  The free Medicare exam only covers screening colonoscopies – not diagnostic colonoscopies. A screening colonoscopy is a procedure performed on a patient of screening age in order to find colon polyps or cancer. A colonoscopy that is performed in order to explain symptoms (e.g. blood in stools, change in bowel movements, etc) is called a diagnostic colonoscopy, which is not covered under the Affordable Care Act. Patients are usually fully liable for at least 20% (and maybe more) of the cost related to a scheduled diagnostic colonoscopy.

  There are some cases where a scheduled screening colonoscopy can become a diagnostic colonoscopy, and in those cases a patient becomes responsible for any out-of-pocket costs related to their deductible, co- insurance or co-pays for standard costs like physician and facility fees. A screening colonoscopy becomes a diagnostic colonoscopy when a physician removes a polyp or takes a biopsy during the procedure. For Medicare patients, a family history of colon cancer or polyps will not automatically transform a screening colonoscopy into a diagnostic one. Some private insurers, however, will do this.

  Beware! Related Services Not Always Covered
  Medicare patients who are eligible to have a colonoscopy screening will pay no deductible, co-pay or co-insurance. However, please be forewarned – Patients may still be responsible for other services, such as anesthesia or medication, associated with the procedure. Some of those who have taken advantage of the “free services,” have been unpleasantly surprised to receive hefty bills. If you receive a bill after a “free” Medicare exam, contact the Elderly Benefit Specialist in your county immediately. He or she can help you determine if these charges are allowable.

  How often is it covered?
  Medicare rules dictate how often you can get a free screening colonoscopy. If you get the test sooner that the time periods listed below, you will likely be fully responsible for the cost.

  • Fecal Occult Blood Test: Once every 12 months.
  • Flexible Sigmoidoscopy: Generally, once every 48 months, or 120 months after a previous screening colonoscopy for people not at high risk.
  • Screening Colonoscopy: Generally once every 120 months (once every 24 months if you’re at high risk), or 48 months after a previous flexible sigmoidoscopy.
  • Barium Enema: Your doctor can decide to use this test instead of a flexible sigmoidoscopy or colonoscopy. This test is covered every 24 months if you are at high risk for colorectal cancer and every 48 months if you aren’t at high risk.

  How do I qualify?
  A Medicare patient can qualify for a screening colonoscopy if they:

  1. Are of the recommended screening age (for people of average risk = age 50 or over, though recent studies indicate that African-Americans may need to start screening at age 45.)
  2. Do NOT have any symptoms
  3. Do NOT have personal history of colon polyps or colon cancer

  A Medicare patient can still qualify for a screening colonoscopy despite having a family history of colon cancer or colon polyps.

  Costs: Screening Colonoscopy

  • Clarifying “Free” Screening Colonoscopies for Medicare Patients
    $0 annual deductible for procedure
  • $0 co-insurance for procedure

  Costs: Diagnostic Colonoscopy

  • $0 annual deductible for procedure
  • 20% co-insurance must be paid for procedure

  Why Should I Get a Screening Colonoscopy?
  Colorectal cancer is the third most commonly diagnosed cancer and the 3rd leading cause of cancer death in both men and women in the US. The great majority of these cancers and deaths could be prevented with early screening. This is because most colorectal cancers develop from
  adenomatous polyps. Polyps are noncancerous growths in the colon and rectum. Detecting polyps through screening and removing them can actually prevent cancer from occurring. Furthermore, being screened at the recommended frequency improves the chance that colorectal cancer will be detected at an earlier stage, when it is more likely to be cured by surgery alone, the surgical procedure is less extensive, and the recovery is much faster.

  (statistics excerpted from AMERICAN CANCER SOCIETY, Colorectal Cancer Facts & Figures 2008-2010.)

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