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New Clarifications on ACA Coverage of Colonoscopy, BRCA Testing

10 October, 2015

The Department of Labor's Employee Benefits Security Administration posted Affordable Care Act Implementation FAQs this month clarifying points related to both screening colonoscopy and BRCA testing.

Questions 7 and 8 both clarified points related to preventive/screening colonoscopy. Here are the questions and answers from the DOL EBSA:

Q7: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost sharing for the required specialist consultation prior to the screening procedure?

No. The plan or issuer may not impose cost sharing with respect to a required consultation prior to the screening procedure if the attending provider determines that the pre-procedure consultation would be medically appropriate for the individual, because the pre-procedure consultation is an integral part of the colonoscopy. As with any invasive procedure, the consultation before the colonoscopy can be essential in order for the consumer to obtain the full benefit of the colonoscopy safely. The medical provider examines the patient to determine if the patient is healthy enough for the procedure and explains the process to the patient, including the required preparation for the procedure, all of which are necessary to protect the health of the patient.

Q8: After a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is the plan or issuer required to cover any pathology exam on a polyp biopsy without cost sharing?

Yes, such services performed in connection with a preventive colonoscopy must be covered without cost sharing. The Departments view such services as an integral part of a colonoscopy, similar to polyp removal during a colonoscopy. The pathology exam is essential for the provider and the patient to obtain the full benefit of the preventive screening since the pathology exam determines whether the polyp is malignant. Since the primary focus of the colonoscopy is to screen for malignancies, the pathology exam is critical for achieving the primary purpose of the colonoscopy screening.

The lack of consistency in coverage of costs for pathology of polyps removed during a screening colonoscopy was identified as a concern in a June 2015 report completed by NCC on cost-sharing issues for colonoscopy with polyp removal. This clarification removes yet another potential burden for those seeking screening colonoscopy as recommended by their physician and the USPSTF.


Question 10 in the FAQs clarifies which women receive coverage with no cost-sharing for genetic counseling and testing with regards to BRCA mutation.

Q10: Which women must receive coverage without cost sharing for genetic counseling, and if indicated, testing for harmful BRCA mutations?

Women found to be at increased risk using a screening tool designed to identify a family history that may be associated with an increased risk of having a potentially harmful gene mutation must receive coverage without cost sharing for genetic counseling, and, if indicated, testing for harmful BRCA mutations. This is true regardless of whether the woman has previously been diagnosed with cancer, as long as she is not currently symptomatic of or receiving active treatment for breast, ovarian, tubal, or peritoneal cancer.

Read the full FAQs report from the DOL here.

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