Section 3.35. Colorectal cancer screening coverage.

 

(1)   Applicability.

(a) This section applies to disability insurance policies as defined at s. 632.895 (1) (a) , Stats., unless otherwise excepted in s. 632.895 (16m) (c) , Stats., that are issued or renewed on or after December 1, 2010. This section applies to Medicare supplement and cost plans but does not include limited –scope plans including vision and dental, hospital indemnity, income continuation, accident-only benefits, and long-term care policies. This section also applies to self-insured health plans as defined at s. 632.745 (24) , Stats.

(b) For a disability insurance policy and a self-insured health plan covering employees who are affected by a collective bargaining agreement the coverage under this section first applies as follows:

1. If the collective bargaining agreement contains provisions consistent with s. 632.895 (16m) , Stats., coverage under this section first applies the earliest of any of the following: the date the disability insurance policy is issued or renewed on or after December 1, 2010, or the date the self-insured health plan is established, modified, extended or renewed on or after December 1, 2010.

2. If the collective bargaining agreement contains provisions inconsistent with s. 632.895 (16m) , Stats., the coverage under this section first applies on the date the health benefit plan is first issued or renewed or a self-insured health plan is first established, modified, extended, or renewed on or after the earlier of the date the collectively bargained agreement expires, or the date the collectively bargained agreement is modified, extended, or renewed on or after December 1, 2010.

(2)   Definitions. In addition to the definitions contained in s. 632.895 (1) , Stats., for purposes of this section all the following apply:

(a) "Designated guideline" means the recommendations of the U.S. Preventive Services Task Force, the National Cancer Institute, or the American Cancer Society regarding colorectal cancer screening guidelines identified by the insurer or self-insured health plan for compliance.

(b) "Enrollee" means an insured or enrollee of a health plan subject to s. 632.895 (16m) , Stats.

(c) "Self-insured health plan" means a self-insured governmental health plan offered by the state, county, city, village, town, or school district that provides coverage of any diagnostic or surgical procedure.

(3)   Colorectal cancer screening guidelines and updates.

(a) Insurers may utilize one or more of the most current colorectal cancer screening guidelines issued by the U.S. Preventive Services Task Force, the National Cancer Institute, or the American Cancer Society as the basis for the coverage offered for preventive colorectal cancer screening tests and procedures. If an insurer or self-insured health plan elects to designate more than one guideline, the insurer or self-insured health plan shall specify the guideline that will be primary in the event of a conflict between the designated guidelines. Insurers shall provide notice of the selected guideline or guidelines and which guideline is primary in a prominent location within the plan summary and in the notice provided to insureds when a benefit is denied based upon the primary guideline.

(b) Insurers and self-insured health plans shall at least annually review the designated guidelines and incorporate modifications to be effective the first day of the subsequent plan year.

(4)   Covered screening. Insurers offering disability insurance and self-insured health plans shall offer as a covered benefit the screening for colorectal cancer that may be subject to limitations, exclusions and cost-sharing provisions that generally apply under the plan and comply with all of the following:

(a) Insurers and self-insured health plans shall cover evidence-based, recommended preventive colorectal cancer screening tests or procedures contained in the most current version of the designated guideline.

(b) In accordance with the most current recommendations from the designated guideline for frequency of testing, insurers and self-insured health plans shall provide as a covered benefit, colorectal cancer screening tests or procedures for enrollees who are 50 years of age or older other than as provided for in sub. (5) (b) . Medically appropriate or medically necessary covered screening tests or procedures shall at least include 3 of the following:

1. Fecal occult blood test.

2. Flexible sigmoidoscopy.

3. Colonoscopy.

4. Computerized tomographic colonography.

(c) Insurers and self-insured health plans may require the enrollee's health care provider or the enrollee's primary care provider to obtain prior authorization for screening tests or procedures when the screening test or procedure is not contained in the most current version of guideline recommendations designated by the insurer or self-insured health plan.

(d) Disputes regarding coverage of medically appropriate or medically necessary evidence-based screening tests or procedures are subject to internal grievance and independent review as provided by ch. Ins 18 .

(5)   Factors for high risk.

(a) In accordance with recommended factors for identifying persons at high risk for colorectal cancer developed by the American Cancer Society, insurers and self-insured health plans shall provide as a covered benefit evidence-based colorectal cancer screening tests and procedures at recommended ages and intervals for enrollees determined to be at high risk for developing colorectal cancer. Insurers and self-insured health plans that designated either the U.S. Preventive Services Task Force or the National Cancer Institute as the designated guideline may include additional high risk factors when the guidelines identify factors for persons at high risk for colorectal cancer. All insurers and self-insured health plans shall at a minimum consider all of the following factors, as appropriate, when determining whether an enrollee is at high risk for colorectal cancer:

1. Personal history of colorectal cancer, polyps or chronic inflammatory bowel disease.

2. Strong family history in a first-degree relative or two or more second-degree relatives of colorectal cancer or polyps.

3. Personal history or family history in a first or second-degree relative of hereditary colorectal cancer syndromes.

4. Other conditions, symptoms or diseases that are recognized as elevating one's risk for colorectal cancer as determined by the U.S. Preventive Services Task Force, the National Cancer Institute or the American Cancer Society.

(b) Notwithstanding sub. (4) (b) , insurers and self-insured health plans shall provide as a covered benefit evidence-based, recommended colorectal cancer screening tests or procedures for high risk enrollees no later than the earliest recommended age determined to be medically appropriate or medically necessary.

(c) Disputes regarding an enrollee's status as being at high risk or factors to be considered as high risk for colon cancer are subject to internal grievance and independent review as provided by ch. Ins 18 .

(6)   Preventive services compliance. Notwithstanding s. 632.895 (16m) , Stats., insurers and self-insured health plans shall comply with P.L. 111-148 and 45 CFR 147.130 relating to cost-sharing provisions of preventive services including colon cancer screening.

EmR1042 : emerg. cr. eff. 11-29-10; CR 10-150 : cr. Register June 2011 No. 666 , eff. 7-1-11.