Twenty States Had Laws That Require Private Health Insurance Plans to Cover Colorectal Cancer Screening Tests

Twenty states had laws requiring private health insurance plans to cover  colorectal cancer screening tests as of May 2004. In 19 of these states, the  laws generally applied to group or individual health plans, and required  coverage of all four tests—FOBT, flexible sigmoidoscopy, DCBE, and  colonoscopy—typically consistent with ACS guidelines. However, the law  in Wyoming had limitations. It 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 ACS guidelines. Among plans that covered fewer than four of the tests,  DCBE and colonoscopy were least likely to be covered. In States Without Colorectal Cancer Screening Test Laws, Most of the Small Employer and Individual Plans Reviewed Provided Coverage for All Four Tests

In 10 states without laws requiring private health insurance coverage of  colorectal cancer screening tests, most of the small employer plans we  reviewed—16 of 19—covered all four colorectal cancer screening tests. The remaining 3 plans covered FOBT or FOBT and flexible  sigmoidoscopy, but not DCBE or colonoscopy. Among the 14 individual  plans we reviewed, 10 covered all four colorectal cancer tests for  screening purposes. The remaining 4 plans did not offer screening  coverage for any of the tests. Most Large Employer Plans Reviewed Covered All Four Colorectal Cancer Screening Tests

Twenty-four of the 35 large employer plans we reviewed, or approximately  two-thirds of these plans, covered all four colorectal cancer tests for  screening purposes. Seven of the 35 plans covered only one of the  colorectal cancer screening tests: FOBT or flexible sigmoidoscopy. Four of the health plans offered  by the large employers did not cover any of the colorectal cancer tests for  screening purposes. Among the 17 national FEHBP plans, 12  covered all four tests, and 5 covered FOBT, flexible sigmoidoscopy, and  colonoscopy, but not DCBE. External Comments and Our Evaluation

Representatives of ACS and AHIP provided comments on a draft of this  report. In contrast, AHIP commented that the report overstates the lack  of coverage, for example by highlighting the number of plans that covered  fewer than four tests rather than the number of plans that covered at least  one test. Recognizing that our findings are subject to varying  interpretations, we attempted to report them neutrally and to not overly  emphasize the coverage that did or did not exist. In response to ACS’s comments that we did not  sufficiently address our study limitations, we modified the final report to  more prominently highlight certain limitations of our methodology. AHIP Comments

AHIP commented that the draft report did not sufficiently address the low  rate at which Americans actually receive colorectal cancer screening tests  in spite of relatively high coverage rates among health plans, suggesting  that factors other than insurance coverage are responsible for the low  screening rate. However, an assessment of the factors influencing  screening utilization rates, beyond the extent of health insurance  coverage, was outside the scope of this report. Appendix I: Scope and Methodology

To examine the extent to which the four key colorectal cancer tests are  covered for screening purposes by private health insurance plans, we  reviewed the extent to which state laws require such coverage, and we  reviewed the extent of coverage among selected small employer and  individual plans in states without such laws, a sample of large employer  plans, and coverage within FEHBP plans.
Why GAO Did This Study

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.

What GAO Found

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.