Wednesday, December 31, 2008

NC Department of Insurance : mandated colorectal screening is 'covered' but not 'reimbursed': SO WHAT KIND OF DOUBLE-SPEAK IS THAT?

This is a letter to me, in its entirety, from the NC Department of Insurance, Robert Lisson, PhD, Deputy Commissioner, Consumer Services Division.

This is what the Deputy Commissioner is stating: while state law mandates there be coverage of colorectal screening, the Department of INsurance cannot mandate BCBSNC as re: 'place of coverage'----though this results in non-coverage of colorectal screening----which is the law.

These appear to be the important points associated w/ the 'covered' but lack of 'reimbursement' of colorectal screening by BCBSNC except in an office based setting, of which one site is available and that site is in western NC, in Boone, NC.

Important item #1. colorectal screening is mandated to be covered under NC law, specifically, North Carolina General Statute 58-3-179 . Here is the law:


§ 58-3-179. Coverage for colorectal cancer screening.
(a) Every health benefit plan, as defined in G.S. 58-3-167, shall provide coverage
for colorectal cancer examinations and laboratory tests for cancer, in accordance with themost recently published American Cancer Society guidelines or guidelines adopted by
the North Carolina Advisory Committee on Cancer Coordination and Control for
colorectal cancer screening, for any nonsymptomatic covered individual who is:

(1) At least 50 years of age, or

(2) Less than 50 years of age and at high risk for colorectal cancer
according to the most recently published colorectal cancer screening
guidelines of the American Cancer Society or guidelines adopted by the
North Carolina Advisory Committee on Cancer Coordination and

The same deductibles, coinsurance, and other limitations as apply to similar services
covered under the plan apply to coverage for colorectal examinations and laboratory tests
required to be covered under this section.
(b) Reserved for future codification purposes. (2001-116, s. 1.)


Important Item #2. "The same deductibles, coinsurance, and other limitations as apply to similar services....(are) required to be covered under this section."

Insurance policies have deductibles. Mine is a standard policy with a $2500.00/ year/ person deductible for the usual kinds of things: you get into an accident and you have to stay in the hospital. One expects to pay out of pocket for this. Your son has to have surgery for a condition that was congenital. One expects to pay out of pocket for this. You have to have surgery for something. One expects to pay out of pocket for this. And so are 'similar services' associated with:

a. outpatient services which may be necessary but are not covered by law
b. a service which is covered by law

What is the definition of 'similar services'??

Important Item #3: If a service is covered by law, then why are other matters e.g., 'place of service' allowed to trump the law? If there are no office based gastroenterology practices which provide office based screening colonoscopies within 3 hours of a major metropolis in NC, then de facto isn't there essentially no coverage of the mandated service, specifically, screening colonoscopy?


December 15, 2008
Dr. Marsha Hammond
Asheville, NC 28806

RE: Blue Cross & Blue Shield of North Carolina
------------------- -.­
Dear Dr. Hammond:

Thank you for your recent correspondence to the Consumer Services Division. I am writing in response to your December 13, 2008 em ail message to Becky Thornton, regarding your BCBSNC policy's coverage for colonoscopies in your immediate area.

First, "coverage" and "reimbursement" are two different things. North Carolina health plans subject to North Carolina General Statute 58-3-179 must indeed cover colorectal cancer screening. As you are aware, though, a claim for "covered" services does not always result in reimbursement from the health plan. . For example this could occur when (even after the cost of the covered service) the member has not yet met the applicable policy deductible. In such situations, the cost of the covered service is credited to the member's deductible. If the service were not covered, the cost would not be credited to the deductible.

Second, North Carolina law does not give the Department of Insurance the regulatory authority to dictate place-of-service for this mandated benefit. More specifically, we do not have the authority to require BCBSNC to make the procedure in question available in office-based settings. My understanding is that the procedure can be obtained from in-network BCBSNC providers in your immediate area. Whether the service is available only in contracted clinic settings or also from contracted office-based providers does not affect BCBSNC's compliance with applicable provider availability/accessibility requirements.

We certainly understand your disappointment, and regret that we do not have the authority to further assist you. However, please do not hesitate to contact me at (800) 546-5664 if you wish to discuss the matter.

Robert C. Lisson, Ph.D.
Deputy Commissioner, Consumer Services Division

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