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Seniors and the Screening Loophole

be an advocate fight crc

“But doctor, I thought screening for colorectal cancer was covered by Medicare!?”

Our seniors are facing policy loophole that lands them with an unexpected bill.

In a recent report, Colonoscopy Screening After the Affordable Care Act: Cost Barriers Persist for Medicare Beneficiaries on the colonoscopy copay issue by AARP, there continues to be a debate about what portion of a preventative service a patient should be responsible for.

For our seniors, prior to the implementation of the Affordable Care Act (ACA), Medicare beneficiaries typically incurred some level of cost sharing for health care services they received. For example, they were responsible for Part B premiums, Part B Deductibles, and a 20 percent coinsurance for certain services.

Implementation of ACA

The implementation of the ACA sought to remove these barriers for Medicare patients getting screened for colorectal cancer (CRC).  The ACA eliminated the Part B deductible, as well as the 20 percent coinsurance charges for routine “screening” tests, including a screening colonoscopy.

Are you confused yet? Here’s where we have to bring out the dictionary.

There is a distinction in the policy in how it defines a screening colonoscopy verses a diagnostic colonoscopy. You may have gone in for a screening colonoscopy, having had no signs or symptoms of CRC, and no family history of CRC, but you may wake up to learn that actually your procedure was diagnostic in nature.

If, during your procedure, any one of the three things occurred during your colonoscopy, it will be redefined as a diagnostic colonoscopy, and you may incur a portion of the cost:

1)     If a polyp was found and removed;

2)     If a tissue was biopsied;

3)     If the colonoscopy was done as the result of a positive fecal occult blood test (FOBT).

Furthermore, the private sector insurance providers (not Medicare) recently clarified that a “polyp removal and tissue removal is an integral part of a screening colonoscopy” and therefore should NOT be subjected to any cost sharing.

The differences in how we define when a screening procedures stops and starts has created a lack of uniformity between Medicare patients and private insurance definitions, ultimately impacting cost to patients.

Congress Should Act – H.R. 1070

Congress could act to bring about consistency, and a bill to do just that was introduced (H.R. 1070) although it’s very unlikely to pass this year.

And if you’re wondering about that colonoscopy you might have following a positive FOBT test, Medicare views that procedure as a diagnostic test and you’ll be subject to both your Medicare Part B deductible, as well as a 20 percent coinsurance.

We know this oversight in current Medicare law has resulted in confusion and frustration for our seniors. And we’re doing something about it.

Help us generate as many cosponsors of H.R. 1070 as possible – a bill that removes cost sharing, a barrier to colorectal cancer screening.

Be a part of the solution!

Please ask your representative to cosponsor H.R. 1070 or thank him/her for already doing so. 

To find contact information for your representative, visit http://www.house.gov/representatives/find/

To see the full list of cosponsors and a detailed description of the bill, visit https://www.govtrack.us/congress/bills/113/hr1070.

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