Medicare co-insurance loophole: The value of waiving co-insurance for Medicare beneficiaries

Medicare fully covers colorectal cancer (CRC) screening (screening colonoscopy, fecal immunochemical test, fecal occult blood test, multi-target stool DNA, and flexible sigmoidoscopy); however, if a biopsy or removal of a lesion occurs during the screening colonoscopy, the procedure becomes diagnostic. In addition, a colonoscopy that is performed after a positive stool test is coded as a diagnostic procedure regardless of colonoscopy findings. A diagnostic colonoscopy means the beneficiary may be charged co-insurance.1,2 If waiving this co-insurance would result in a 10-percentage-point increase in adherence, MISCAN-Colon estimated there would be 13% fewer CRC deaths and approximately a 0.6% increase in CRC-related costs for the Centers for Medicare and Medicaid Services. Moreover, if removing the co-insurance increased the overall CRC screening rate by 0.6%, it would be considered cost-effective legislation. Therefore, the waiver is likely to have a favorable balance of health and cost impact. Methods and recommendations are described in more detail in Peterse et al., 2017.

1 Medicare Coverage for Screening Colonoscopies

2 Insurance Coverage for Colorectal Cancer Screening