Will Your Colonoscopy Be Free on a HDHP?

A High-Deductible Health Plan (HDHP) is a plan with a higher deductible than a traditional health insurance plan. In exchange for a higher deductible, the monthly premium is usually lower, but you pay healthcare costs out-of-pocket before your insurance company starts to pay.

Colonoscopy as the gold standard for colon screening

Certain preventive screenings are covered at 100 percent under HDHPs, and it is important that you take advantage of these privileges because they are an integral part of wellness and disease prevention. One of the most important preventive screenings is a colonoscopy, a test that can detect and prevent colon cancer. Colon cancer is the third leading cause of cancer death among men and women in the United States, and it is estimated that over 95,000 people will be diagnosed with the disease this year.
Although home stool tests can help detect cancer, colonoscopy is the gold standard for colon cancer screening because your doctor can view the entire length of the colon to evaluate the health of your digestive tract. If any polyps are discovered, your doctor can typically remove them during the procedure before they have the chance to develop into cancer.

How will I know when I should get a colonoscopy?

If you are at average risk for colon cancer, you should get your first screening colonoscopy at the age of 50. If you are African American, you should schedule your first colonoscopy at age 45. Having a family history of colon cancer or polyps or personal history of polyps also may lower the recommended age for your baseline colonoscopy, but you will need to talk to your doctor to determine your optimum age to be screened.

The difference between screening colonoscopies and diagnostic colonoscopies

There are two types of colonoscopy: screening and diagnostic. Screening colonoscopies are coded and covered differently than diagnostic colonoscopies. The amount an insurance provider will pay toward a colonoscopy depends on how the procedure is coded.

A screening colonoscopy is performed on an asymptomatic patient of screening age to examine for colon polyps or cancer. Your HDHP provider should cover screening colonoscopies as part of Affordable Care Act (ACA) preventive healthcare, but there are certain conditions that have to be met. You must choose an in-network gastroenterologist and an in-network hospital or facility such as an ambulatory surgery center (ASC). If you go out-of-network, you may be subject to cost sharing. Choosing an in-network doctor and facility can result in a difference of hundreds of dollars.

Before scheduling your screening colonoscopy, you should make a list of questions to ask your insurance provider to help determine your financial responsibility. Some of these questions should include, but are not limited to:

  • I am _________ years old. Am I eligible for a screening colonoscopy under my current policy? NOTE: Most plans will offer colonoscopy benefits at 50 years of age. If you have a family history of colon cancer or polyps, you will have to provide the age of the first-degree relative at the time of diagnosis and ask for the information to be noted in your medical records.
  • Is Dr. ______________ [your preferred physician] in-network and covered under my policy? What percentage of that doctor’s charges are covered?
  • Is ______________ [your preferred hospital or ambulatory surgery center] in-network and covered under my policy? What percentage of the facility charges are covered?
  • Will I have out-of-pocket costs for anesthesia? (some providers will waive deductibles and co-insurance for anesthesia costs, but you should ask your provider during this phone call).
  • If the doctor finds that I have a colon polyp, will the pathology costs be covered?

Depending on your plan, most insurance companies pay for the actual screening procedure at 100 percent. However, there may be cost sharing for anesthesia or pathology charges. This depends entirely on your individual plan. Even if you have no personal or family history of colon cancer or polyps and this is your baseline colonoscopy, it is important to ask your provider about medical coverage if a polyp is found and needs to be removed.

A diagnostic colonoscopy is a procedure that is requested when symptoms are present or when another screening procedure comes back positive. In this case, you should expect to be responsible for the charges if you have not met your annual deductible. You should call your insurance company to inquire about coverage and out-of-pocket expenses. Ask your insurance provider the same questions listed above, but also request information about your financial responsibility for the procedure itself, as well as anesthesia and polyp removal (if required) and if you need further care.

Making informed choices with your HDHP
After you speak to your insurance provider, you should begin price comparing. Just as you would shop around before making any other large purchase, you should compare prices of doctors and facilities. There is no standard cost for a colonoscopy, and you may find that several gastroenterologists in your area have widely varying costs. It is often more economical to have your colonoscopy performed at an ambulatory surgery center (ASC) because of their personal service, convenient access, shorter wait times and lower cost. By calling around to find low-cost, high-quality healthcare, you will be making informed decisions about how you spend your healthcare dollars.

Take the time to do some research so that you can make an informed decision. Whether you are making decisions about a health plan, doctor, facility or procedure, do your homework. A little bit of planning can make all the difference when the bill arrives.