Does Medicaid or private insurance cover cancer screenings?

You know what lifestyle habits to implement to lower your risk of cancer. You know what screenings you need based on your age. But, what’s not straightforward is how to get screened affordably and how to navigate insurance.

Insurance can feel over-complicated and stressful. Way too stressful. If you’re missing or postponing screenings because of insurance confusion, here is the information you need so you don’t have to put your health in jeopardy.

What services are fully covered under Medicaid? What services are fully covered under private insurance?

The U.S. Preventive Services Task Force (USPSTF)—a group of medical experts who establish recommendations on certain health services, such as cancer screenings—assign a letter grade (A, B, C, D or I) to recommend for or against medical services, based on clinical evidence. Per the Affordable Care Act (ACA), Medicaid and private insurers are required to cover services, without cost sharing (including copays or deductibles), that are given an “A” or “B” grade. You can also view the full USPSTF grading system to see how each grade is defined and what that means for coverage.

Here is a list of cancer preventive-related services that currently have an “A” or “B” (and are therefore fully covered by Medicaid or private insurance):

Risk assessment/reduction

• Risk assessments for women with personal or family histories of breast, ovarian, tubal or peritoneal cancer or who have ancestry associated with BRCA-1 or BRCA-2 gene mutations. After the risk assessment, women with positive risk assessment should receive genetic counseling and, if indicated after counseling, genetic testing.
• Prescriptions for risk-reducing medications for women 35 and older who are at increased risk for breast cancer and at low risk for adverse effects. Women at increased risk may include those with extensive family history of cancer (especially with family members with cancer younger than age 50), personal history of atypical breast conditions, increased breast density, being overweight or obese, and certain hormone and reproductive factors.

Screenings

• Breast cancer screening for women at average risk ages 50-74. Note: Prevent Cancer Foundation recommends getting routine mammograms starting at age 40. The USPSTF gives a “C” grade for mammograms for women ages 40-49, but this service has been protected by congressional action until 2025.
• Cervical cancer screening for women at average risk ages 21-65.
• Colorectal cancer screening for adults at average risk ages 45-75.
• Hepatitis B virus (HBV) infection screening for adolescents and adults at increased risk and for pregnant women. People at increased risk include those born in or have parents born in a country outside of the U.S. with a high prevalence of HBV infection, people who inject drugs, men who have sex with men, people with human immunodeficiency virus (HIV), and the sex partners or household contacts of people who have HBV infection.
• Hepatitis C virus infection screening for adults ages 18-79.
• Lung cancer screening for adults ages 50-80 who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.

Counseling and interventions

• Skin cancer counseling about minimizing exposure to ultraviolet (UV) radiation for young adults, adolescents, children and parents of young children with fair skin.
• Tobacco cessation interventions for adults.
• Tobacco use prevention education and counseling for school-aged children and adolescents.
• Unhealthy alcohol use screening and counseling for adults 18 and over.

That means, under current law, if you have health insurance and qualify, these preventive services are covered. Read the full list of services, including those not related to cancer. Recommendations are reviewed and updated periodically, so check the list for the most current version.

What about screenings that aren’t recommended by the USPSTF?

The above list highlights routine cancer screenings that must be covered because of the ACA. Private insurers may choose to cover additional services, such as skin cancer checks, prostate cancer screenings or lung cancer screenings for those who quit smoking more than 15 years ago. In addition, screening that have a “C” grade from the USPSTF may be covered based on your personal and family health history and other risk factors; it’s important to talk to your doctor and check with your insurance plan for more details.

Are there any loopholes? What’s the catch?

Some insurance plans that were in place prior to the passage of the ACA in 2010 may not offer the aforementioned coverage. Depending on the state you live in, there may be laws that require private insurance companies and state plans, such as Medicaid, to cover some cancer screening services. Talk with your insurance company to determine your level of coverage. There is also a legal challenge (Braidwood Management Inc. v. Becerra) before the 5th U.S. Circuit Court of Appeals that could impact the future of zero cost-sharing guarantee for preventive services. While the case is under appeal, these services remain fully in effect.

To be certain about your coverage, ask your insurance company how much you should expect to pay before you get a screening. In some cases, the results of a screening could change the cost, so ask about this, too. For example, if a polyp is removed during a colonoscopy, the procedure code may change from “screening” to “diagnostic,” and you can be charged.

What do I do if I don’t understand my insurance plan?

The most helpful action to take may be to call your insurance company. To prepare for the call, have your insurance documents ready. Take notes during the call and ask clarifying questions, even if it feels like you should already know the answer.

What do I do if I don’t have insurance?

There are many programs that offer free or low-cost cancer screenings and vaccinations. You can also contact your local hospital or health care facility to ask if they cover routine cancer screening, testing and vaccination through their foundations or outreach programs (including mobile testing).

Remember, Early Detection = Better Outcomes. Take charge of your health and schedule your routine cancer screenings today.

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