The battleground states for colonoscopy laws

Colonoscopy reimbursements, along with other GI procedures, are declining, placing financial strain on physicians and limiting access for patients. 

From 2007 to 2022, unadjusted and adjusted average reimbursement for GI procedures dropped by 7% and 33%, respectively, according to a study published in the American Journal of Gastroenterology. Reimbursements for colonoscopy and biopsy decreased by 38% during that period. 

Meanwhile, the demand for colonoscopies is increasing. In 2021, an advisory panel lowered the recommended age for initial colorectal cancer screenings from 50 to 45. CMS also said on Nov. 1, 2023, that it would expand Medicare coverage for certain colorectal cancer screening tests, lowering the minimum age for coverage from 50 to 45.

However, financial barriers persist for patients. A recent study found that only 17% of patients pay nothing for their bowel preparation before a screening colonoscopy, and nearly half are directed toward using non-FDA-approved, over-the-counter regimens. Study leader Eric Shah, MD, a gastroenterologist at the University of Michigan, told Becker's about a loophole in which prescription drugs for screening prep are tied to screening costs, resulting in higher out-of-pocket expenses for Medicare patients.

"If patients have to pay out of pocket for the prep, it could lead them to delay screening, especially given the current economy," Dr. Shah said. "If someone puts off screening because of $19, that's a real problem. We need to reduce those barriers."

Another challenge arises when a screening colonoscopy becomes diagnostic. In such cases, patients must pay 15% of the Medicare-approved amount for physician services. In ASCs, they may also face a 15% coinsurance fee.

To address these issues, several states have introduced or passed legislation to expand colonoscopy reimbursement coverage. Here are five states leading the charge:

California

A proposed state senate bill would require insurers to cover colorectal cancer screening that holds an A or B grade from the U.S. Preventive Services Task Force or an equivalent recommendation from a certified agency such as the American College of Gastroenterology.

Illinois

In August, Illinois Gov. J.B. Pritzker signed House Bill 2385, mandating insurance coverage for all colonoscopies for patients exhibiting symptoms of colon cancer or having an existing colon condition. As of Jan. 1, Illinois is one of four states expanding colonoscopy coverage.

Kentucky

As of Jan. 1, insurers in Kentucky must cover "any cancer screening or test" consistent with nationally recognized clinical guidelines. These screenings must be covered without cost-sharing or utilization management requirements.

Nebraska

A new law that took effect on Jan. 1 requires insurance companies to cover all aspects of colorectal cancer screenings. This includes polyp removal, pathology examination of polyp biopsies, required specialist consultations before screenings, prescribed bowel preparation medications, and anesthesia services associated with preventive colonoscopies.

Vermont

As of Jan. 1, Vermont insurers must cover CRC screenings in accordance with national recommendations for average-risk individuals, eliminating patient cost-sharing. Previously, coverage was only required for individuals aged 50 and older.

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