Q. I read in the paper that preventative screening for cancer is federally mandated to be covered by my health insurance company at no cost to me. My doctor recommended a colonoscopy and now the insurance company says I have to pay part of the cost. I believe this is a violation of the president's new health policy. I believe the insurance company should reverse its decision.


A. We've been contacted by a number of consumers who have had similar experiences. Let's begin by taking a look at the requirements in the Affordable Care Act and Oregon law. Essentially, most health benefit plans are required to include coverage for preventative health services and the plans are prohibited from imposing cost-sharing, like co-pays or deductibles. One of the preventative services is screening for colorectal cancer, including colonoscopy in adults beginning at age 50, so it would seem that you should not have to pay anything. It turns out, however, that there are circumstances where cost sharing does apply. Here are some of the situations we've investigated.

  • The procedure was not preventative. In general, the procedure will be considered preventative if you're healthy, you are age 50-75, and the purpose is screening for cancer. If the procedure is ordered because you're experiencing disease symptoms, or as a follow up to prior treatment, then it may not be considered preventative.
  • Surgery was required. Sometimes during the screening your doctor will discover a polyp and will remove it. This may be considered surgery, and there may also be lab work involved to be sure the polyp is benign. If these services are separately billed, there may be cost sharing involved.
  • The doctor is out of network. If the doctor is not a preferred provider with your insurance plan, then there may be cost sharing.
  • Your plan is "grandfathered." This is kind of confusing, but the law only applies to plans that are new or substantially changed. If you have a grandfathered plan, the new requirements do not apply.
We suggest talking with your doctor and your insurance company to find out what will be paid by the insurance company and what you may have to pay before having this procedure. It's a good habit to get into for any medical procedure.

If you run into problems with your insurance company, you can always contact the Oregon Insurance Division at (888) 877-4894 and an advocate can assist you.
Q. My wife was recently diagnosed with cancer and went through surgery. We found a promising follow up treatment but the insurance company has denied payment because they say the treatment is experimental or investigational. We appealed and got the same result. We hired a lawyer and are just filing for external review. We contacted the Insurance Division but you appear powerless to do anything, even though you tried.


A. Thankfully, medical science is constantly developing new medicines and treatments. However, experimental or investigational treatments are typically excluded in health insurance contracts until such time as there is enough evidence to support their safety and effectiveness. You've identified an important safeguard in Oregon law to make sure insurance companies apply this exclusion appropriately: external review.

Insurers in Oregon offering health benefit plans are required to have an external review program. This means your wife's medical records and any other documentation you wish to submit may be reviewed by independent medical professionals. The State of Oregon contracts with several external review organizations which are assigned at random and are not affiliated with the state or the insurance company. There is no charge to you for this process.

Independent reviewers must base their determination whether the decision of an insurer should be upheld or overturned on expert clinical judgment, after considering relevant medical, scientific and cost-effectiveness evidence and medical standards of practice in the United States. About a third of the denials are overturned.

While we can't always get the desired result, our advocacy team is available to help when you experience difficulties with your insurance company or agent. Advocates answer questions, explain processes, and may contact the insurance company on your behalf to be sure the company is in compliance with the law and the terms of the contract. We can also help you understand the appeals process and what types of materials may be helpful to make your case. An appeals guide is available on our website: www.cbs.state.or.us/ins/consumer/appeals-guide/appeals-guide.pdf. The advocacy line is (888) 877-4894.
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