Health Plans Face Decisions Over Preventive Screenings Coverage – SHRM

Under the Affordable Care Act, nongrandfathered private health plans—including employer-sponsored group health plans—must cover certain preventive services given a rating of “A” or “B” by the
U.S. Preventive Services Task Force without cost-sharing, within certain guidelines. Breast, colorectal, cervical and lung cancer diagnostic screening tests have all been assigned an A or B rating by the task force.

Issues remain around coverage, however, including whether plans should pay the full costs of newer tests that have not received the task force’s A or B rating, or provide full coverage of advanced follow-up testing after initial diagnostic exams indicate a problem.

Here are examples of how regulatory and legislative actions at the federal and state level are altering preventive screening coverage or may do so in the future.

Colorectal Cancer and Colonoscopies

In 2016, the task force recommended screening for colorectal cancer for those ages 50 to 75; however, “some consumers went in for a screening colonoscopy that they expected to be free only to receive significant bills after their procedure was coded as diagnostic,” according to Katie Keith, director of the Health Policy and the Law Initiative at the O’Neill Institute for National and Global Health Law at Georgetown University, writing for
the Health Affairs Forefront blog. Federal oversight agencies subsequently clarified that coverage without cost-sharing applied to prescreening consultations with a specialist, preparation medications, anesthesia, and polyp removal and biopsies.

Subsequently, in May 2021, the task force extended its recommendation for colorectal cancer screening to those ages 45 to 49. In addition, new multiagency
guidance issued in January “confirms that insurers and plans are required to cover a follow-up colonoscopy, without cost-sharing,” if there are indications of colon-related bleeding, for all people ages 45 and older, Keith wrote. Health plans must provide this coverage without cost-sharing for plan years beginning on or after May 31, 2022.

Spreading the Message on Colorectal Cancer Prevention

March is
National Colorectal Cancer Awareness Month and the Colorectal Cancer Alliance is sharing a
social media toolkit on the value of colonoscopies and other colorectal screening tests.

In a March
article that encourages spreading the word about colon cancer detection, Craig Wilson, director of health policy for the Arkansas Center for Health Improvement, wrote that “screening is the key to reducing colorectal cancer deaths. New affordable, non-invasive, take-home options for screening have been added to the traditional colonoscopy to encourage more detection. However, screening rates remain low compared to rates for breast and cervical cancer screenings.”

This, he indicated, is “due to multiple barriers, including patient fear or embarrassment, knowledge gaps, scheduling difficulties, language or cultural differences, or financial barriers.”

CAC Scans for Heart Disease

Dr. R. Philip Eaton, the emeritus executive vice president for health sciences at the University of New Mexico Health Sciences Center, spent three legislative sessions advocating that New Mexico require insurance plans to cover a relatively inexpensive and proven test that can identify a person’s risk for developing heart disease with a high degree of accuracy.

The test, called the
coronary artery calcium (CAC) scan, is a CT scan that takes 10 minutes and costs around $100 to $150 on average. Results are interpreted by a score system in which the lower the score, the lower the presence of calcified plaque in the heart.

The
New Mexico legislation, which passed in 2020, mandates that commercial insurers, including self-insured employer health plans, cover the cost of the test for people ages 45 to 65 and deemed at “intermediate risk” for cardiovascular disease.

When state legislators learned about the test, they wanted to take it themselves, Eaton said. “Almost all of them had a CAC scan,” he noted. “They had me call their doctors. They didn’t wait for the law to pass. … There were so many of them who [tested] positive.”

Yet, outside the legislative chambers, Eaton hasn’t seen a commensurate increase in awareness about the test. “I don’t know how to get the message out,” he said. “It’s not getting across very fast.”

In addition to New Mexico, only Texas mandates coverage of the test. A similar bill has also been re-introduced in the Connecticut legislature for 2022.

St. Louis-based cardiologist Anthony Pearson, who publishes
The Skeptical Cardiologist blog and advocates for wider use of the CAC scan, concurred with Eaton—he’s never seen it mentioned in corporate health and wellness communications.

“I’ve worked at a couple different places in the last 10 years, and neither place, with all the stuff that comes out of HR on wellness and other things, mentioned anything about CAC or any other vascular screening,” he said. “Anything that spreads good information around about preventive cardiology and the utilization of the CAC would be a good thing and of benefit to employees. It could help keep them alive.”

Eaton and his colleagues published a
comparison between the CAC scan and colonoscopy during the course of their advocacy; they pointed out that heart disease kills 600,000 Americans a year, while colon cancer kills 50,000.

The U.S. Preventive Services Task Force, however, has not rated the CAC scan, though the American Heart Association and American College of Cardiology have endorsed it since 2018 as an
additional element in determining risk.

Becoming a CAC Scan Advocate

W. Scott Matthews, a co-founder of Tremendousness, a St. Louis-based communications firm, had been told by his doctor that his cholesterol levels were “a little high.” When he took the CAC scan, it showed mild plaque formation, putting him at intermediate risk for heart disease. The results, he said, brought him clarity and persuaded him to adopt a healthier lifestyle. Now an advocate for the test, Matthews created an animated
YouTube video about his experience.

Awareness of the CAC scan “is phenomenally low,” Matthews said. He encourages people to “find out if they might be helped by getting it, and if they work for a large company, to go to HR and find out if it’s covered, and why or why not.”

A Multicancer Screening Test

Health insurance issuers and self-funded health plans may want to consider providing coverage of a new multicancer screening test, some health specialists recommend.

A March
article in the
Health Affairs journal noted that “there is a tremendous public health need to identify potentially lethal cancers at earlier stages, when there is a greater chance for improved survival,” and that “new tests can screen for up to 50 cancers simultaneously based on a simple blood draw.”

Multicancer screenings, however, face hurdles to acquiring coverage by health insurers. “Lack of insurance coverage for multicancer early detection screening tests could exacerbate existing care disparities among cancer patients,”
HealthPayer Intelligence reported, while “coverage of this tool could reduce care disparities by making screenings and preventive care more accessible.”

Further Efforts to Expand Diagnostic Coverage

Mandated health plan coverage for diagnostic tests—some cutting-edge, others well-established—is advancing through legislation or regulation at the state and federal levels. In addition to the federal actions that expanded required coverage of colorectal exams and state activity on CAC scans, these examples are noteworthy:

State action on biomarker testing. In 2021 three states—Illinois, Louisiana and California—passed laws mandating that health plans cover biomarker blood testing that can help pinpoint mutations most susceptible to treatment by genetically designed specialty drugs. While specialty drugs can be expensive, narrowing down those which may be most effective might save treatment expense as well as lives, coverage advocates say. The American Cancer Society’s Cancer Action Network is planning to
expand its lobbying efforts around biomarker test coverage to 12 additional states in 2022.

Federal action on breast cancer. New legislation—the
Access to Breast Cancer Diagnosis Act—has been introduced in the U.S. Senate and House of Representatives. This measure would require full coverage for additional diagnostic breast cancer tests if routine mammograms indicate a possible malignancy, including follow-up mammograms, ultrasound and biopsies, which currently
entail out-of-pocket costs for patients. Requiring plans to pay for breast cancer biopsies would be in line with the newly expanded requirements for colonoscopies, which include full coverage for polyp removal and evaluation, supporters of the bill said.

Plan Design and Public Policy Implications

A March 2022
research report by the nonprofit Employee Benefits Research Institute (EBRI) in Washington, D.C., found that use of preventive services—including cancer screenings—decreased when enrollees moved from a traditional preferred provider organization (PPO) health plan to an high-deductible health plan (HDHP) that shifted more pre-deductible spending onto health care users.

“Our results are consistent with and extend prior findings that use of health care services decline when individuals with chronic conditions move from a PPO to a HDHP,” said Paul Fronstin, EBRI’s director of health benefits research. 

He advised, “Such findings can help employers make targeted benefit design decisions. They can also inform policymakers as they grapple with allowing employers to provide enhanced coverage for health care services that prevent the exacerbation of chronic conditions.”

Greg Goth is a freelance health and technology writer based in Oakville, Conn.