Cancer Screening and Prevention Under Health Reform

Your chances of surviving cancer are much better when you find it early. The Affordable Care Act makes it possible for you to have free cancer screening tests.

Cancer screening tests are a type of preventive medical service. They are included as part of the essential health benefits that must be covered by any health plan you enroll in from your state's health insurance Marketplace. In fact, most plans must offer certain free cancer screening tests even if you did not buy them through  a Marketplace.

Free Cancer Screening Tests

Experts have learned that screening tests for certain types of cancer can save lives. Here's what you need to know about screenings for some common cancers.

Breast cancer . Breast cancer is the most commonly diagnosed cancer in women. It is also the second leading cause of cancer deaths among women. Mammograms can help find breast cancer early. This screening is just one part of preventive care women can get without having to pay a copay or coinsurance or meet an annual deductible.

Check with your insurance company to find out your coverage. Some plans only cover mammograms every two years, and others pay for them every year. Under some plans, you have to be 40 or older to receive a free mammogram. The American Cancer Society recommends that you wait until age 45 to have a mammogram. If you are high-risk, you might be able to receive a mammogram earlier

Insurance plans that existed before March 2010 and were not substantially modified are called “grandfathered health plans” and might not offer free preventive care. Always check your coverage before scheduling a screening test.

Cervical cancer . Regular Pap tests and tests for HPV, the human papillomavirus, can help find cervical cancer early.

The Affordable Care Act requires that most private health plans provide Pap tests and cervical cancer screening every 3-5 years without asking women to pay a copay or coinsurance. Women older than 30 may have HPV testing every 3 years, regardless of Pap smear results.

If you have Medicare, you won't be charged for Pap tests and pelvic exams. Medicaid also covers Pap tests, but the details vary from state to state.

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Colon cancer. Nine out of 10 people survive long-term if their colon cancer is caught early. However, just 40% of colorectal cancers are found at that early stage. If the cancer spreads to nearby organs or lymph nodes, the 5-year survival rate goes down to 70%. If it spreads to distant organs, your survival rate drops to 12%.

Under the Affordable Care Act, private health plans must offer one of several different types of screening tests for colon cancer. After age 50, you can receive a fecal blood test, a sigmoidoscopy, or a colonoscopy without owing a copay or coinsurance. Again, this does not apply to grandfathered plans so be sure to check your plan's summary of benefits.

Medicare coverage also offers free colon cancer screening tests. It's possible, though, that you might have to pay copay for the doctor’s visit, anesthesia, or hospital visit.

What Medicaid will cover depends on which state you live in.

Lung cancer. Lung cancer is the number one cancer killer of both men and women in the U.S.

If you are a longtime smoker, you may be able to get free testing under lung cancer screening guidelines adopted in 2015.

The test is a once-a-year, low-dose CT scan. You could get this screening if all of these are true for you:

  • You're 55 to 80 years old
  • You have smoked one pack a day for 30 years
  • You now smoke, or have quit in the past 15 years

Lung cancer screening is seen as a preventive measure, just like cervical and colon cancer screening tests. Medicare and Medicaid also offer free screenings. This benefit may not be available to you if you are in a grandfathered health plan.

Rules on Free Screening Tests

Here's what you should know about cancer screening tests:

Does everyone get a free screening? People who are in grandfathered health plans may not be eligible for these benefits.Call your insurance company to see if you get free screening tests. Otherwise, you might need to meet your plan’s deductible or pay a copay or coinsurance at the time of your appointment.

Your state might require that private health plans and Medicaid offer free screenings. Call your state health department or Medicaid office to see what is covered. Medicare does cover cancer screenings free of charge.

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Keep in mind, though, that screening tests without any extra costs are just for people who don’t have any symptoms. If you have symptoms and your doctor orders a colonoscopy, it is not considered a preventive screening test and is likely to come at a charge . If you have colon cancer and get a colonoscopy, it is not free either. In both of these cases, a colonoscopy is a diagnostic test, not a screening test.

Can I make an appointment just for the free screening? You can schedule a cancer screening by itself or as part of your annual checkup. For some screenings, you might need a separate visit to the doctor. A colonoscopy is one example. You can have others, like a Pap test, during a regular checkup.

Can anyone get a screening at any time? You must follow your health plan’s guidelines to get preventive screening tests. For example, you have to be 50 or older to get a colon cancer screening without having to pay for it. If you have a high risk of colon cancer, you can get checked every 2 years no matter how old you are without paying any costs. If you have an average risk, you can get a free colonoscopy only once every 10 years without paying.

Are follow-up tests and biopsies free, too? No. Follow-up tests and biopsies are diagnostic tests, not screenings. You may have to meet your plan’s deductible or pay a copay or coinsurance to your doctor and hospital if you need more testing.

If the screening shows I have cancer, is my treatment free? Most people will have copays, coinsurance, and deductibles for any cancer treatment. In some states, Medicaid covers some women with cervical cancer. This applies to women whose cancer was found through the National Breast and Cervical Cancer Early Detection Program.

WebMD Medical Reference Reviewed by Sarah Goodell and Michael W. Smith, MD on November 29, 2017

Sources

SOURCES:

World Health Organization: "Early Detection of Cancer."

Community Catalyst and the Center for Health Insurance Studies, Georgetown University Health Policy Institute: "Essential Benefit Package."

U.S. Department of Health and Human Services: "Preventive health services for adults;" "Preventive health services for women;" and  "Affordable Care Act Rules on Expanding Access to Preventive Services for Women."

U.S. Preventive Services Task Force: "USPSTF A and B Recommendations;" and "U.S. Preventive Services Task Force Issues Draft Recommendation Statement on Screening for Lung Cancer."

American Cancer Society:  "Medicare Coverage for Cancer Prevention and Early Detection;" "Colorectal cancer screening -- state and federal coverage laws;" "Cervical cancer prevention and screening: Financial issues;" and "What Women Should Know About Cervical Cancer and the Human Papilloma Virus."

American Lung Association: "Lung Cancer Fact Sheet."

Medicare Rights Center: "Medicare Coverage of Pap Smears, Pelvic Exams and Physical Breast Exams."

Centers for Disease Control and Prevention: “Cancer Among Women.”

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