After Polyps Are Detected, Patients Might no Longer Qualify For Free Colonoscopies

Insurance coverage of colonoscopies to screen for colorectal cancer is a frequent source of frustration for consumers, including a reader who asks about his situation. In addition to his query, this week I additionally address questions about Medicare premiums and delays in determining Medicaid eligibility.

Q: When I had a screening colonoscopy in 2021, the doctor removed a polyp and told me to return for an additional colonoscopy in three years. I paid nothing for that 2021 test because it was a preventive screening. After i scheduled my appointment for this year, the company said the process was diagnostic because of that earlier polyp removal. Doesn't what the law states protect individuals these situations from being charged for additional frequent but necessary screening?

Not necessarily. The Affordable Care Act greatly expanded coverage of preventive services, including requiring commercial insurers to pay for screenings for colorectal cancer without charging patients anything out-of-pocket if they are between ages 50 and 75. Generally, screening colonoscopies for individuals at average risk are recommended every 10 years by the U.S. Preventive Services Task Force. (Under the law, preventive services are covered free of charge by insurers when they meet the task force's recommendations.) There is no charge to the patient for the test, even if a benign growth called a polyp is found and removed.

Doctors may recommend more frequent “surveillance” testing, because they did for you personally, if during screening they find any polyps, which might place you at higher risk for cancer of the colon. Because the task force doesn't have a recommendation for high-risk colorectal cancer screening, insurers aren't necessary to cover it without cost sharing.

“Insurers covers the exam, but if the patient is held harmless for the copay and deductible depends on the insurer,” said Dr. J. Leonard Lichtenfeld, deputy chief medical officer in the American Cancer Society.

Medicare also covers screening colonoscopies without charging beneficiaries anything out-of-pocket. This program covers tests every Ten years, and each 2 yrs if a person is recognized as high-risk. There is however a catch: As opposed to private coverage, if a polyp is located throughout the test, that procedure is then considered diagnostic and patients will be susceptible to a copayment.

Q: I signed up for a plan on healthcare.gov last fall in Virginia after I lost my employer coverage and found that my 16-year-old daughter might be eligible for Medicaid. Two months have passed, and that we still do not have a solution. I understand that her coverage is going to be retroactive to the date we applied, on the other hand, I have to pay any medical bills. The state says it has 45 days to consider, but we're past that. So what can I actually do?

Even although the authorities allows states 45 days to act on a Medicaid application, a couple weeks is typical and “at this time it's well past the acceptable range of time for getting an eligibility determination,” said Tricia Brooks, a senior fellow at Georgetown University's Center for Children and Families.

If you have not done this already, confirm that the Virginia Medicaid program has gotten the application and find out specifically what they desire of your stuff to do something onto it. If you're racking up medical bills, let Medicaid officials know that your funds is critical and consider asking your daughter's providers to contact them too, Brooks said.

In many states, including Virginia, local legal-aid societies, community health centers along with other groups are on hand to assist sort out application glitches although the open enrollment period has ended. Browse the Get Covered Connector for links to assisters in your town.

Q: I’m a federal government retiree receiving a small Social Security payment. I'm trying to figure out why I'm paying $134 every month let's focus on my Medicare Part B premium instead of $109. I signed up at age 65, and it's deducted from my Social Security check. From what I've read, if you're having premiums deducted from Social Security, you generally pay $109. Why shall we be held paying more?

The standard monthly premium for Medicare Medicare part b, which provides coverage for many outpatient services and physician visits, is $134 in 2021, unchanged from this past year. Recently, many Medicare beneficiaries happen to be resistant to Part B premium increases because by law they ought to be “held harmless” if the premium increases are bigger than their Social Security benefit increases, which have generally been flat.

This year, for most people those circumstances have changed. Due to a 2 percent cost-of-living adjustment to Social Security benefits, 42 percent of Medicare part b enrollees are actually subject to the entire $134 Medicare Part B premium, according to the Centers for Medicare and Medicaid Services.

From your description it sounds as if you are one people, said David Lipschutz, senior policy attorney in the center for Medicare Advocacy.