Colonoscopy Coverage and the Affordable Care Act

Colonoscopy Coverage and the Affordable Care Act

Colonoscopy coverage and the aca affordable care act

Colonoscopy coverage can differ between insurers and whether the procedure is classified as screening or diagnostic. This could have an impact on your out-of-pocket expenses.

Under the Affordable Care Act (ACA), screening colonoscopies for colorectal cancer must be covered without cost sharing as part of preventive services. This policy was put in place to safeguard patients from unexpected bills when their stool-based test comes back positive.


Medicare, the federal health insurance program for seniors, covers colonoscopy procedures as routine screening tests or to diagnose issues. Original Medicare also pays for flexible sigmoidoscopies – a similar but less invasive procedure that doesn’t involve viewing the entire colon – if your doctor has determined you have an increased risk of developing colorectal cancer.

Under the Affordable Care Act (ACA), health insurers and plans must cover preventive services without cost-sharing, such as screening colonoscopies. Unfortunately, there have been instances in which both health insurers and patients have been unpleasantly surprised by unexpected expenses.

Sarah, a woman named Sarah, had her first screening colonoscopy and was surprised when the bill for the procedure exceeded $1,000. When Sarah contacted her health insurer about it, they informed her that the service had been coded as diagnostic rather than screening, meaning she would need to cover part of the expense.

The ACA preventive benefit for screening colonoscopies is meant to promote regular screening, yet many adults worry about unexpected charges. This could deter people from seeking care and make it more challenging for them to receive necessary treatments.


Medicaid also covers colonoscopies as a screening test for people at high risk, similar to Medicare. Depending on your age and risk level, you can have this test every 24 months or every 10 years.

Screening colonoscopies are typically covered by commercial insurers without any out-of-pocket expenses if they meet the recommendations of the US Preventive Services Task Force. They’re also covered under Medicare Advantage plans if the doctor performing the procedure is in-network.

The Affordable Care Act (ACA) also expanded Medicaid coverage to more people under 65, creating new requirements for applications and renewals with the purpose of encouraging enrollment and decreasing churn.

In accordance with the Affordable Care Act (ACA), Medicaid must implement a “community rating” system that seeks to reduce healthcare costs for beneficiaries by stimulating competition among health insurance providers. This is achieved by enrolling Medicaid recipients into managed care organizations (MCOs) instead of traditional fee-for-service programs. MCOs are paid a monthly capitated rate to provide comprehensive care and control total expenses.

Private Insurance

One of the best ways to prevent colorectal cancer is through regular screening colonoscopies. Under the Affordable Care Act (ACA), insurance companies must cover these procedures without charging patients out-of-pocket if they meet federal guidelines.

However, there are a few exceptions. Insurers sometimes have more leeway to charge when the procedure is classified as diagnostic rather than for screening purposes.

The United States Preventive Services Task Force recommends that those at average risk receive screening colonoscopies every 10 years.

Though federal guidance lays the foundation of this practice, insurers often differ in how they interpret it and how their claims payment systems apply cost sharing based on provider coding.

Unexpected bills for colonoscopies can be a deterrent to seeking screening, so consumers should call their health insurance provider before scheduling a screening to find out how much they must pay and what steps need to be taken in order to avoid such fees.

Self-Insured Plans

When it comes to colonoscopy procedures, there are various ways of securing coverage. Some individuals are covered by commercial insurers while others rely on self-funded health plans for coverage.

Under the Affordable Care Act, all major medical plans that are not grandfathered must provide preventive services without deductibles or copays. Furthermore, it defines preventive care broadly to include a range of activities experts believe to be essential for healthy individuals.

Colonoscopies are one of the more expensive preventive services, often costing between $1,000 and $2,000 or more. Unfortunately, these costs may not be covered by most health plans, discouraging people from getting screened.

Regulations under the Affordable Care Act (ACA) mandate insurers to abide by United States Preventative Services Task Force guidelines for colorectal cancer screening. Furthermore, they require them to offer cost-sharing protection to patients who require follow-up colonoscopies after a positive screen or direct visualization of a polyp.

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About the Author: Raymond Donovan