The Affordable Care Act requires coverage of recommended cancer screenings

A law that changed the price of a test

The Affordable Care Act was signed in March 2010. One small part of it changed what a cancer screening test costs at the counter.

Most health plans must cover a set list of preventive services with no copay, no coinsurance, and no deductible. CMS says the rule began with new health policies whose plan years started on or after September 23, 2010. It applies when a network provider does the test.

Cancer screening makes up a large share of that list.

Who writes the list

Insurers do not write it. Three bodies do.

The U.S. Preventive Services Task Force is a panel of independent experts. It ranks each service by how strong the evidence is. Anything it grades A or B goes on the list. CMS names breast and colon cancer screening as examples.

The Advisory Committee on Immunization Practices sets the vaccine part. That includes the HPV vaccine. Our page on HPV vaccination explains what it prevents.

A third route covers care for women, infants, children, and teens.

What is on the list

HealthCare.gov spells it out.

For adults: colorectal cancer screening from age 45 to 75. Lung cancer screening for adults 50 to 80 who smoked heavily, or who quit in the past 15 years. Tobacco screening, and help with quitting.

For women: a screening mammogram every one to two years from age 40. Cervical cancer screening, including a Pap test from 21 to 65. Genetic counseling about BRCA for women at higher risk.

The numbers behind each line

Each entry rests on a Task Force statement with real thresholds in it.

Breast. The Task Force advises a mammogram every two years for women aged 40 to 74. Our guide to mammograms covers what the visit is like.

Colon and rectum. Screening for all adults 50 to 75, graded A. Screening for adults 45 to 49, graded B.

Cervix. Cytology, better known as a Pap test, every 3 years from 21 to 29. From 30 to 65, a Pap every 3 years, or a test for high-risk HPV every 5 years, or both together every 5 years.

Lung. A yearly low-dose CT scan for adults 50 to 80 with a 20 pack-year history who smoke now or quit within 15 years. A pack-year means one pack a day for one year.

The second half of a stool test

A stool test is cheap and easy. It is also only half of a screen. A positive result means little until someone looks inside the colon.

For years, plans billed that second step as a diagnostic test, with full cost sharing. Large bills followed. Some people skipped the colonoscopy.

Federal guidance closed the gap. In FAQs Part 51, the agencies state that a plan must cover a colonoscopy done after a positive stool test, or after an abnormal sigmoidoscopy or CT colonography, with no cost sharing, for the people the Task Force recommendation covers. The reason given is plain. Without the follow-up, the screening is not complete.

The same guidance treats the bowel prep medicine, the anesthesia, removal of any polyp, and the pathology exam on that polyp as part of the screening colonoscopy. They are not extras.

Our page on what happens after a positive at-home stool test walks through the next steps.

When to get checked

These are the ages the covered list runs on. They describe people at average risk who feel well.

• Age 45: start colorectal screening.
• Age 40: start talking about mammograms. Every two years is the current advice, through 74.
• Age 21: start cervical screening, and keep it up to 65.
• Age 50 to 80, with 20 pack-years, smoking now or quit within 15 years: ask about a yearly low-dose CT.

Screening is for people with no symptoms. Symptoms are a different track. Blood in the stool, a change in bowel habit that lasts more than a few weeks, a new breast lump, bleeding between periods or after sex, a cough that will not clear, or weight loss you cannot explain all need an appointment now. They do not wait for the next screening date.

What this does not mean

It does not mean every plan. Plans that existed on March 23, 2010 and were not changed much after that are called grandfathered. They sit outside the rule.

It does not mean any provider. HealthCare.gov notes that free coverage generally applies in network, and that zero cost is not guaranteed in every case.

It does not mean every test. Once a test is done to work up a symptom or a known problem, it counts as diagnostic, and normal cost sharing returns.

It does not mean the list is fixed. The Task Force updates its statements, and the covered set moves with them. Our page on the benefits and harms of screening covers what screening can and cannot do. Before a test, it helps to ask your plan whether the provider is in network and how the visit will be coded.

Sources

• CMS, The Affordable Care Act's New Rules on Preventive Care — https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/preventive-care-background
• HealthCare.gov, Preventive care benefits for adults — https://www.healthcare.gov/preventive-care-adults/
• HealthCare.gov, Preventive care benefits for women — https://www.healthcare.gov/preventive-care-women/
• CMS, FAQs About Affordable Care Act Implementation Part 51 — https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-Part-51.pdf
• USPSTF, Breast Cancer: Screening — https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
• USPSTF, Colorectal Cancer: Screening — https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
• USPSTF, Cervical Cancer: Screening — https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening
• USPSTF, Lung Cancer: Screening — https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening

How this article was prepared

An AI-assisted editorial system helped prepare this page. No named medical reviewer has reviewed it unless one is listed.

The National Cancer Information Foundation publishes Cancer Explained. This page is for learning. It is not medical advice and does not suggest a test or treatment.

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