CT Colonograpy/Virtual Colonoscopy & Cologuard in Grandfathered Health Plans

The Affordable Care Act is the demarcation line between Grandfathered health plans and Non-grandfathered health plans. A Grandfathered health plan is a  group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. March 23, 2010 is the effective date of the Affordable Care Act.

Grandfathered plans are exempted from many changes required under the Affordable Care Act. For example, preventive care/wellness benefit is not free in grandfathered plans. There is no limit on out-of-pocket maximums in grandfathered plan. On the other hand, preventive care is free in non-grandfathered plans. There are limitations on out-of-pocket maximums in non-grandfathered plan.

CT Colonograpy & Cologuard screenings are not mandatory in Grandfathered Health Plans. But if a health plan under grandfathered plan covers colorectal cancer screenings as a wellness benefit, this benefit will include coverage for CT Colonograpy and Cologuard. In that case, scenarios will be as follows:

Typical Scenario for CT Colonograpy or Virtual Colonoscopy:

Benefit Limit: Once in every 5 years

Place of Treatment: As defined by the health insurance companies

Age Limit: 50-75 years or 76-85(network providers)

Claim will apply contract benefits. In case of members aged 76-85, prior authorization is required. Claims for members aged less than 50 or greater than 85 will be denied.

CPT4 and Diagnosis codes: Specific CPT4 and Diagnosis codes will have to be used. Otherwise, claim will be denied.

Providers: Specific provider types as defined by the health insurance companies will have to be used.

In case of out-of-network providers, claim will apply out-of-network contract benefits.

Typical Scenario for Cologuard:

Benefit Limit: Once in every 3 years

Place of Treatment: As defined by the health insurance companies

Age Limit: 50-75 years or 76-85(network providers)

Claim will apply contract benefits. In case of members aged 76-85, prior authorization is required. Claims for members aged less than 50 or greater than 85 will be denied.

CPT4 and Diagnosis codes: Specific CPT4 and Diagnosis codes will have to be used. Otherwise, claim will be denied.

Providers: Specific provider types as defined by the health insurance companies will have to be used.

In case of out-of-network providers, claim will apply out-of-network contract benefits.

Age: 50-75 years or 76-85(network providers)

Claim will apply contract benefits. In case of members aged 76-85, prior authorization is required. Claims for members aged less than 50 or greater than 85 will be denied.

CPT4 and Diagnosis codes: Specific CPT4 and Diagnosis codes will have to be used. Otherwise, claim will be denied.

Providers: Specific provider types as defined by the health insurance companies will be have to used.

In case of out-of-network providers, claim will apply out-of-network contract benefits.