Many patients struggle to understand the various rules relating to healthcare costs. As deductibles and overall patient liability rise, patients determine what healthcare needs are most important and balance this with financial realities. The good news about colonoscopy screenings is they are most likely covered under your plan benefits as a free service to patients, with insurance paying the bill!
The Patient Protection and Affordable Care Act (PPACA), which became effective January 1, 2011, requires commercial healthcare insurance plans to cover preventive services – without any cost sharing – for patients between the ages of 50 and 75.
However, since the passing of PPACA, there has been much confusion. With the right information, most patients who fit the criteria for a screening colonoscopy may now get one with no out-of-pocket cost. Patients should always contact their insurance carrier prior to any procedure to verify benefits and potential costs, even if their provider does the same.
Some plans consider a patient with a personal history, and sometimes a family history, to be a diagnostic procedure instead of a screening, and therefore may not waive the patient financial responsibility. If the plan is out-of-network with the provider, benefits may not follow PPACA, which could result in cost to the patient. Plans that are self-funded or fall into a “grandfathered” status do not have to follow the PPACA guidelines. So there are many rules and loopholes for payers, and it can leave patients scratching their heads wondering where they fit in.