New York state Medicaid expansion of coverage for colorectal cancer screening

New York state (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) plans, inclusive of Mainstream MMC Plans, HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs), as well as Health and Recovery Plan (HARP), have expanded current colorectal cancer screening coverage to include enrollees 45 to 49 years of age. This expansion is in response to recently updated recommendations by the United States Preventive Services Task Force (USPSTF). New information suggests earlier screening has a moderate net benefit and should be considered for individuals at average risk for colorectal cancer. The USPSTF continues to state, with high certainty, that screening for colorectal cancer in individuals 50 to 75 years of age have substantial net benefit. For additional information regarding colorectal cancer screening, providers can visit the USPSTF Colorectal Cancer: Screening web page.

Colorectal cancer is the third leading cause of cancer-related deaths in NYS, with almost 3,000 deaths reported in the state annually. Studies show that early detection can increase the five-year survival rate by as much as 75%. All Medicaid members between 45 to 75 years of age at average risk for colorectal cancer should be offered screening with one of the recommended screening test options. Screening members at high risk for colorectal cancer should be done sooner than screening of average risk individuals and should be based on clinical decision. Although cancer screening rates have increased over the last few years, it is estimated almost 30% of NYS residents between 50 to 75 years of age are not up to date with their colorectal cancer screening.

NYS Medicaid providers should notify all their adult patients about their risk for colorectal cancer and discuss screening test options with them. Studies show that patients are more likely to be screened for colorectal cancer if they are offered test options. Providers, taking patient preferences into consideration, may order the most appropriate colorectal cancer screening methods from Table 1. The recommended frequencies listed in Table 1 are for patients considered to be of average risk of developing colorectal cancer.

Table 1: Colorectal cancer screening methods for patients considered to be of average risk Method Recommended frequency Fecal immunochemical test (FIT) or high sensitivity fecal occult blood testing (FOBT) [Once annually FIT-DNA* (such as Cologuard) Once every three years Computed tomography colonography (CTC) Once every five years Flexible sigmoidoscopy (SIG) Once every 10 years Colonoscopy Once every 10 years SIG with FIT Once every 10 years (SIG) plus once every year (FIT)

* DNA - deoxyribonucleic acid, in this case based from stool and any blood shed therein.

 

Reminders:

• The colorectal cancer screening methods included in Table 1 may be used for individuals considered to be at high risk. In general, however, screening with colonoscopy is the preferred method for most individuals at high risk for colorectal cancer.
• More frequent colorectal cancer screening methods may be considered medically necessary for individuals considered to be at high risk of developing colorectal cancer.
• It is important to discuss with patients that positive results from the screening methods outlined in Table 1, other than colonoscopy, may result in the need for diagnostic colonoscopies.

• Colorectal cancers should be considered possible diagnoses in patients (regardless of age) presenting with blood in their bowel movements, changes in bowel habits, abdominal pains, weight losses, or unexplained anemias. In such situations, the USPSTF and the American Cancer Society^® (ACS) recommend clinical decision making to determine whether diagnostic colonoscopies should be performed.
• NYS Medicaid considers colorectal cancer screening by any method not listed above experimental and investigational at this time.

 

Questions and additional information:

• For more information and resources related to colorectal cancer screening, visit the NYS Department of Health (DOH) colorectal cancer web page at http://www.health.ny.gov/diseases/cancer/colorectal.
• Questions regarding Medicaid FFS policy should be directed to the Division of Program Development and Management (DPDM) by phone at 518-473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee’s MMC plan. For MMC plan information, providers can visit the NYS Medicaid Program Information for All Providers – Managed Care Information document at: https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers_

           Managed_Care_Information.pdf, hosted on the eMedNY website.

 

NYE-NU-0363-21 September 2021