In May 2021, the U.S. Preventative Services Task Force (USPSTF) released an updated recommendation for colorectal cancer screening. The USPSTF continues to recommend screening for colorectal cancer in all adults aged 50 to 75 years as an “A” rating but adds screening for colorectal cancer in adults aged 45 to 49 years as a “B” rating.
In addition, the recommendation regarding screenings says that when stool-based tests reveal abnormal results or positive results, follow-up with a colonoscopy is needed for further evaluation in order for the screening benefits to be achieved.
On January 10, 2022, the DOL, HHS, and Treasury issued guidance that discusses the coverage of colonoscopies in accordance with the USPSTF recommendations. The guidance refers to the May 2021 updated USPSTF recommendation and states that after a positive non-invasive stool-based screening test or direct visualization test, a “follow-up colonoscopy is an integral part of the preventive screening, without which the screening would not be complete.” The guidance further states that “[t]he follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization screening test is therefore required to be covered without cost-sharing in accordance with the requirements of PHS Act section 2713 and its implementing regulations.” As a result, a health plan must cover and may not impose cost-sharing with respect to a colonoscopy conducted after an abnormal or positive non-invasive stool-based screening test or direct visualization screening test for colorectal cancer for individuals described in the USPSTF recommendation.
Therefore, the guidance requires group health plans and insurers (except for grandfathered health plans) to provide coverage with no cost-sharing for preventive screenings for colorectal cancer in adults beginning at the age of 45. In addition, the requirement to provide coverage for preventive screenings for colorectal cancer at no cost-sharing extends to follow-up colonoscopies after an abnormal or positive non-invasive stool-based screening test or direct visualization screening test as recommended by the USPSTF and clarified in federal guidance. Carriers and self-insured plans, other than grandfathered plans, are expected to provide coverage for the recommended colorectal cancer screenings (i.e., USPSTF recommendations with a rating of “A” or “B”) without cost-sharing for plan years beginning on or after May 31, 2022 (i.e., starting with June 1, 2022 plan years).