Thursday, December 10, 2020

Medicare Fix: Colorectal Screening Act to Remove Copays from Colonoscopy Biopsies

Update: I understand that the Colonoscopy Copay bill HR 1570 is expected to pass House & Senate in the year-end omnibus budget bill, 12/21.  That bill is also expected to contain out of network legislation.


A few days ago, I discussed the introduction of H.R. 8845, a bill that would require Medicare to cover multi-cancer liquid biopsy screening tests upon FDA approval (here).  Here's another Medicare fix, H.R. 1570, a bill which would remove copays from colonoscopy biopsies.  It actually passed the House this week (but so did dozens of other tiny bills).

  • See the bill text here as a PDF.
    • Note that this version confounds a colorectal section (pp 1-5) with a drug pricing section (pp 5-11).
  • See the CBO score here.
  • See the GOV webpage for the bill here.
  • For some new trade press see here.   It sounds like HR 1570 'passed' the House in 12/2019 "inside of" HR3, but it is now re-introduced on its own two feet as HR 1570 for a direct vote on Dec 9 (here)
  • See an Amer J Managed Care sponsored article on colorectal cancer screening policy here. PDF here.

I haven't tracked this issue in detail.  I know for years, there were Medicare policy (theological) debates like these.  (1) A screening colonoscopy that finds nothing is billed as a screening test, no copay, but if you find and remove a polyp, does it become a diagnostic surgical procedure (copay)?  (2)  If you go direct to a screening colonoscopy, it's a no-copay screening service.  But if the same screening colonoscopy is triggered by a positive screening fecal test, is it now a diagnostic workup of the positive screening result?     See American Cancer Society here.[*]  See 2018 article in Stat here.  See  ...And so on.   

Similar issues arise in other screening services.  For example screening mammography finds a shadow, and the biopsy is considered a diagnostic surgical procedure.  Similarly for low dose screening CT for smokers - find a mass and it's a copay biopsy.  Ironically, in the lab test industry, this can be a good thing, because the original LDCT service had to go through oneous USPTF and NCD review, whereas a blood test to "work up" the mass or shadow becomes "diagnostic" and therefore requires only a quick LCD.   


This is a tricky area because the current "" online version is very short (here) and a PDF version online elsewhere at is pretty complex and convoluted legalese (here).  The PDF version, while titled the Colorectal Screening Act, switches on page 5 to a lengthy discussion of drug pricing reporting rules.  



Per American Cancer Society, "But if you have a screening test other than colonoscopy and the result is positive (abnormal), you will need to have a colonoscopy. Some insurers consider this to be a diagnostic (not screening) colonoscopy, so you may have to pay the usual deductible and co-pay."  And CMS says, "If a found and may pay 20% [copay]...".  Here.

Regarding a family history and BRCA screening, Kaiser Family Foundation notes that due to a transmittal from HHS, under preventive services in ACA, both genetic counseling and BRCA testing are covered without copay (here).  At this webpage, see "FAQ Set 12 Q6."   This is good because the USPSTF benefit is really focused on genetic counseling.  However, if you have Medicare, it doesn't cover genetic counseling ever and it doesn't cover a BRCA test unless you have a personal history of cancer. 

To see the diversity of floor actions in the House, here.  Go to Dec 8 and HR 1570.