Insurance Circular Letter No. 4 (2022)

March 31, 2022

STATUTORY AND REGULATORY REFERENCES: 42 U.S.C. § 300gg-13; N.Y. Insurance Law §§ 3216, 3221, and 4303; 11 NYCRR 52 (Insurance Regulation 62)

I. Purpose

The purpose of this circular letter is to advise insurers authorized to write accident and health insurance in this state, article 43 corporations, health maintenance organizations, student health plans certified pursuant to Insurance Law § 1124, municipal cooperative health benefit plans, and prepaid health services plans (collectively, “issuers”) of the requirements regarding coverage for preventive care and screenings for colorectal cancer under comprehensive health insurance policies.

II. Discussion

Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) require issuers that deliver or issue for delivery an insurance policy or contract in New York providing hospital, surgical, or medical care coverage, except for a grandfathered health plan,¹ to provide coverage for preventive care and screenings at no cost-sharing. This coverage requirement includes evidence-based care and screenings with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (“USPSTF”).

On May 18, 2021, the USPSTF issued an updated recommendation for colorectal cancer screening. The USPSTF continues to recommend screening for colorectal cancer in all adults aged 50 to 75 years as an “A” rating and adds screening for colorectal cancer in adults aged 45 to 49 years as a “B” rating. In addition, the “Practice Considerations” section of the recommendation regarding screenings provides that when stool-based tests reveal abnormal results or positive results, follow-up with a colonoscopy is needed for further evaluation in order for the screening benefits to be achieved. The recommendation also states that abnormal findings identified by flexible sigmoidoscopy or CT colonography screening require a follow-up colonoscopy for screening benefits to be achieved.

On January 10, 2022, the U.S. Departments of Labor, Health and Human Services, and the Treasury (the “federal Departments”), issued guidance that discusses the coverage of colonoscopies pursuant to USPSTF Recommendations. The guidance refers to the May 2021 updated USPSTF recommendation and states that after a positive non-invasive stool-based screening test or direct visualization test, a “follow-up colonoscopy is an integral part of the preventive screening, without which the screening would not be complete.” The guidance further states that “[t]he follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization screening test is therefore required to be covered without cost sharing in accordance with the requirements of PHS Act section 2713² and its implementing regulations.” As such, an issuer must cover and may not impose cost-sharing with respect to a colonoscopy conducted after an abnormal or positive non-invasive stool-based screening test or direct visualization screening test for colorectal cancer for individuals described in the USPSTF recommendation.

Issuers are reminded that section 52.76(a)(2) of 11 NYCRR (Insurance Regulation 62) requires an issuer to update coverage requirements for preventive care and screenings upon any policy or contract issuance or renewal that occurs six months after the date the recommendation or guideline is issued or revised. Since the USPSTF recommendation was considered issued as of May 31, 2021,³ issuers must provide coverage for the recommended colorectal cancer screening without cost-sharing for policies or contracts issued or renewed on and after November 30, 2021.

III. Conclusion

In accordance with Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3), all issuers, except for grandfathered health plans, must provide coverage at no cost-sharing for preventive screenings for colorectal cancer in adults beginning at the age of 45. In addition, the requirement to provide coverage for preventive screenings for colorectal cancer at no cost-sharing extends to follow-up colonoscopies after an abnormal or positive non-invasive stool-based screening test or direct visualization screening test as recommended by the USPSTF and clarified in federal guidance. Issuers, other than grandfathered plans, are expected to provide coverage for the recommended colorectal cancer screenings without cost-sharing for policies or contracts issued or renewed on and after November 30, 2021.

Please direct any questions regarding this circular letter by email to [email protected].

Very truly yours,

Lisette Johnson
Chief, Health Bureau

¹A “grandfathered health plan” means coverage provided by an issuer in which an individual was enrolled on March 23, 2010, for as long as the coverage maintains grandfathered status in accordance with 42 U.S.C § 18011(e). Ins. Law §§ 3216(i)(17)(F), 3221(l)(8)(G), and 4303(j)(4).

² Public Health Service (“PHS”) Act § 2713, as amended by the Affordable Care Act, is codified at 42 U.S.C. § 300gg-13.

³ Generally, USPSTF recommendations are considered to be issued on the last day of the month in which the USPSTF publishes or otherwise releases the recommendation. 75 FR 41726, 41729 (July 19, 2010).