Private Health Insurance:

Coverage of Key Colorectal Cancer Screening Tests is Common but Not Universal

GAO-04-713: Published: Jun 17, 2004. Publicly Released: Jul 19, 2004.

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Colorectal cancer is the second leading cause of cancer deaths in the United States. Its mortality can be reduced through early detection and treatment. Four key tests are used to detect the cancer--fecal occult blood test (FOBT), flexible sigmoidoscopy, double-contrast barium enema (DCBE), and colonoscopy. Private health insurance plans generally cover these tests to diagnose cancer; however, the extent to which plans cover the tests for screening purposes--where no symptoms are evident--is less clear. Congress is considering legislation that would require coverage of the tests for screening purposes among all private health insurance plans. GAO was asked to (1) identify the state laws that require private health insurance coverage of these screening tests; and (2) determine the extent to which the tests are covered among small employer, individual, large employer, and federal employee health plans. GAO summarized state laws that require coverage of the tests. GAO examined test coverage among a sample of the largest 19 small employer and 14 individual plans in 10 states without laws requiring the coverage, and among 35 large employer plans nationally. The findings cannot be generalized beyond these plans. GAO also reviewed brochures for 143 federal employee health plans.

Twenty states had laws in place as of May 2004 requiring private insurance coverage of colorectal cancer tests for screening purposes. In 19 of these states, the laws generally applied to insurance sold to small employers and individuals, and required coverage of all four tests--FOBT, flexible sigmoidoscopy, DCBE, and colonoscopy. The law in 1 of the states was more limited in scope, applying to group and managed care plans and not explicitly requiring coverage of each of the four screening tests according to American Cancer Society (ACS) guidelines. Most, but not all, health plans offered by the insurers and employers GAO reviewed covered all four colorectal cancer tests for screening purposes. Over four-fifths of the small employer plans (16 of 19) covered all of the tests, whereas 1 plan covered only FOBT and flexible sigmoidoscopy and 2 plans covered only FOBT. Almost three-quarters of the individual plans (10 of 14), covered all of the tests, and the remaining 4 plans covered none of the tests. Approximately two-thirds of the large employer plans (24 of 35) covered all four of the tests. Among the remaining 11 plans, 5 covered only FOBT, 2 covered only flexible sigmoidoscopy, and 4 covered none of the tests. Over half of the plans offered to federal employees covered each of the four tests. Finally, among all plans that covered at least one but fewer than four tests, DCBE and colonoscopy were least likely to be covered. In commenting on a draft of this report, ACS suggested that the report overstated the extent of coverage and did not sufficiently highlight the methodological limitations of the study. In contrast, America's Health Insurance Plans (AHIP) commented that the report overstated the lack of coverage. Moreover, AHIP commented that the report did not address the low rate at which Americans actually receive colorectal cancer screening tests regardless of insurance coverage, suggesting that factors other than health insurance coverage are responsible for low screening rates. Recognizing that the findings are subject to varying interpretations, GAO attempted to report them neutrally. Although the draft report disclosed the methodological limitations of the study, in response to ACS comments, GAO more prominently highlighted certain of the limitations. Finally, whereas the draft report noted the screening utilization rates, assessing the factors responsible for them was beyond the scope of this study.

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