Wiki Screening Colonoscopy : Federal Regulations mandate coverage to INCLUDE biopsy???

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CynthiaHSG13

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I just read Title 42 of Code of Federal Regulations, which to my optimistic eyes seems to be saying that biopsies should be included in the cost of a screening colonoscopy (ie covered in full even if polyps are removed).
Does anyone else have the same or different interpretations?

"Expansion of coverage of colorectal cancer screening tests.
Effective January 1, 2022, colorectal cancer screening tests include a planned screening flexible sigmoidoscopy or screening colonoscopy that involves the removal of tissue or other matter or other procedure furnished in connection with, as a result of, and in the same clinical encounter as the screening test."


 
My interpretation of the language is that screening colonoscopies that include biopsies are to be considered screenings for coverage purposes and not diagnostic procedures, so yes, they should be covered in full with no patient cost-share. I don't see any mention here about the biopsies being included in the cost of the procedure though. A procedure with a biopsy is going to cost more than a screening with no biopsies and I don't think the law changes that.
 
Also, not all plans are subject to the regulation if they maintained their pre-ACA grandfathered status, then this won't apply to those plans.
 
Yes, patient cost-share. Thank you, Thomas.

CBlennie, thank you for that clarification. I always forget about the grandfathered plans. Did you know there are grandmothered plans, too, lol? (https://www.verywellhealth.com/grandfathered-health-plans-4582142).

Medicare also wrote themselves an exemption to this ruling*. The exemption states that when a screening colonoscopy includes a biopsy, the coinsurance will gradually decrease as follows:• 2023–2026, coinsurance is 15% • 2027–2029, coinsurance is 10% • Starting 2030, no coinsurance.

*MLN Matters Number: MM12656 https://www.cms.gov/files/document/...procedures-furnished-during-same-clinical.pdf
 
CynthiaHSG13 said:
Yes, patient cost-share. Thank you, Thomas.

CBlennie, thank you for that clarification. I always forget about the grandfathered plans. Did you know there are grandmothered plans, too, lol? (https://www.verywellhealth.com/grandfathered-health-plans-4582142).

Medicare also wrote themselves an exemption to this ruling*. The exemption states that when a screening colonoscopy includes a biopsy, the coinsurance will gradually decrease as follows:• 2023–2026, coinsurance is 15% • 2027–2029, coinsurance is 10% • Starting 2030, no coinsurance.

*MLN Matters Number: MM12656 https://www.cms.gov/files/document/...procedures-furnished-during-same-clinical.pdf
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Correct. Cost-sharing when a screening colonoscopy converts to diagnostic is being phased out over several years, but until 2030 there will be some cost sharing by the patient.
 
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