United States General Accounting Office 

GAO Report to the Ranking Minority Member, 

Committee on Health, Education, Labor, 

and Pensions, U.S. Senate 

June 2004 PRIVATE HEALTH 

INSURANCE 

Coverage of Key 

Colorectal Cancer 

Screening Tests Is 

Common but Not 

Universal 

GAO-04-713


a
Highlights of GAO-04-713, a report to the 

Ranking Minority Member, Committee on 

Health, Education, Labor, and Pensions, 

U.S. Senate 

Colorectal cancer is the second 

leading cause of cancer deaths in 

the United States. Its mortality can 

be reduced through early detection 

and treatment. Four key tests are 

used to detect the cancer—fecal 

occult blood test (FOBT), flexible 

sigmoidoscopy, double-contrast 

barium enema (DCBE), and 

colonoscopy. Private health 

insurance plans generally cover 

these tests to diagnose cancer; 

however, the extent to which plans 

cover the tests for screening 

purposes—where no symptoms are 

evident—is less clear. Congress is 

considering legislation that would 

require coverage of the tests for 

screening purposes among all 

private health insurance plans. 

GAO was asked to (1) identify the 

state laws that require private 

health insurance coverage of these 

screening tests; and (2) determine 

the extent to which the tests are 

covered among small employer, 

individual, large employer, and 

federal employee health plans. 

GAO summarized state laws that 

require coverage of the tests. GAO 

examined test coverage among a 

sample of the largest 19 small 

employer and 14 individual plans in 

10 states without laws requiring the 

coverage, and among 35 large 

employer plans nationally. The 

findings cannot be generalized 

beyond these plans. GAO also 

reviewed brochures for 143 federal 

employee health plans. 

June 2004 

PRIVATE HEALTH INSURANCE 

Coverage of Key Colorectal Cancer 

Screening Tests Is Common but Not 

Universal 

Twenty states had laws in place as of May 2004 requiring private insurance 

coverage of colorectal cancer tests for screening purposes. In 19 of these 

states, the laws generally applied to insurance sold to small employers and 

individuals, and required coverage of all four tests—FOBT, flexible 

sigmoidoscopy, DCBE, and colonoscopy. The law in 1 of the states was 

more limited in scope, applying to group and managed care plans and not 

explicitly requiring coverage of each of the four screening tests according to 

American Cancer Society (ACS) guidelines. 

Most, but not all, health plans offered by the insurers and employers GAO 

reviewed covered all four colorectal cancer tests for screening purposes. 

Over four-fifths of the small employer plans (16 of 19) covered all of the 

tests, whereas 1 plan covered only FOBT and flexible sigmoidoscopy and 2 

plans covered only FOBT. Almost three-quarters of the individual plans (10 

of 14), covered all of the tests, and the remaining 4 plans covered none of the 

tests. Approximately two-thirds of the large employer plans (24 of 35) 

covered all four of the tests. Among the remaining 11 plans, 5 covered only 

FOBT, 2 covered only flexible sigmoidoscopy, and 4 covered none of the 

tests. Over half of the plans offered to federal employees covered each of 

the four tests. Finally, among all plans that covered at least one but fewer 

than four tests, DCBE and colonoscopy were least likely to be covered. 

In commenting on a draft of this report, ACS suggested that the report 

overstated the extent of coverage and did not sufficiently highlight the 

methodological limitations of the study. In contrast, America’s Health 

Insurance Plans (AHIP) commented that the report overstated the lack of 

coverage. Moreover, AHIP commented that the report did not address the 

low rate at which Americans actually receive colorectal cancer screening 

tests regardless of insurance coverage, suggesting that factors other than 

health insurance coverage are responsible for low screening rates. 

Recognizing that the findings are subject to varying interpretations, GAO 

attempted to report them neutrally. Although the draft report disclosed the 

methodological limitations of the study, in response to ACS comments, GAO 

more prominently highlighted certain of the limitations. Finally, whereas the 

draft report noted the screening utilization rates, assessing the factors 

responsible for them was beyond the scope of this study. 

www.gao.gov/cgi-bin/getrpt?GAO-04-713. 

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Kathryn G. 

Allen at (202) 512-7118. 
Contents 


Letter 1 

Results in Brief 3 

Background 5 

Twenty States Had Laws That Require Private Health Insurance 

Plans to Cover Colorectal Cancer Screening Tests 9 

Majority of Health Plans Reviewed Covered the Four Colorectal 

Cancer Screening Tests 9 

External Comments and Our Evaluation 12 

Appendix I Scope and Methodology 

Appendix II State Laws Requiring Private Health Insurance 

Coverage of Colorectal Cancer Screening Tests 

Appendix III GAO Contact and Staff Acknowledgments 20 

GAO Contact 20 

Acknowledgments 20 

Related GAO Products 

Tables 

Table 1: State Laws Requiring Private Insurance Coverage of 

Colorectal Cancer Screening Tests 9 

Table 2: Coverage of Colorectal Cancer Screening Tests Among 19 

Small Employer and 14 Individual Health Plans Reviewed 

in 10 States 10 

Table 3: Coverage of Colorectal Cancer Screening Tests Among 

Health Plans Offered by 35 Large Employers Reviewed 11 

Table 4: Coverage of Colorectal Cancer Screening Tests Among 17 

National FEHBP Plans 11 

Table 5: State Colorectal Cancer Screening Laws for Private Health 

Insurance 18 

Page i GAO-04-713 Colorectal Cancer Screening Test Coverage 

15 

18 

21 
Abbreviations 

ACS American Cancer Society


CDC Centers for Disease Control and Prevention 


DCBE double-contrast barium enema 


FEHBP Federal Employees Health Benefits Program 


FOBT fecal occult blood test 


OPM Office of Personnel Management


USPSTF United States Preventive Services Task Force 


This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page ii GAO-04-713 Colorectal Cancer Screening Test Coverage 
United States General Accounting Office 

Washington, DC 20548 

June 17, 2004 


The Honorable Edward M. Kennedy 


Ranking Minority Member


Committee on Health, Education, Labor, 


and Pensions 


United States Senate 


Dear Senator Kennedy: 


Colorectal cancer is the second leading cause of cancer deaths in the


United States. Over 146,000 new cases of colorectal cancer will be 


diagnosed and almost 57,000 people will die from the disease in 2004, 


according to the American Cancer Society (ACS). The mortality associated 


with colorectal cancer can be reduced through early diagnosis and 


treatment. Four key tests—fecal occult blood test (FOBT), flexible


sigmoidoscopy, double-contrast barium enema (DCBE), and 


colonoscopy—are commonly used to detect colorectal cancer or its 


symptoms. ACS recommends that individuals at high risk for developing 


the disease and all individuals who reach age 50 receive one or more of


these tests on a regular basis for screening purposes, regardless of


whether they exhibit symptoms of the disease. Private health insurance 


plans generally cover these four tests to diagnose suspected cases of 


cancer when symptoms are present; however, the extent to which plans 


cover the tests for screening purposes is less clear.


Private health insurance plans are offered through different market


segments—such as the small employer, individual, or large employer 


segments, or the health plans offered to federal employees.1

 Some 


previous surveys of the extent of colorectal cancer screening coverage 


among private health insurance plans have been limited to only certain 


health plans or market segments. Moreover, laws that may require 


coverage of the screening tests among health plans sold by insurers vary 


from state to state. Congress is considering legislation that would require 


coverage of colorectal cancer screening tests among all private health 


1

Small employers—typically with 100 or fewer employees—usually purchase health 

insurance plans from insurers on behalf of their employees, while larger employers 

typically fund their own health plans. In the individual market, individuals purchase health 

insurance plans directly. 

Page 1 GAO-04-713 Colorectal Cancer Screening Test Coverage 
insurance plans.2

 At your request we have examined the extent to which 

private health insurance plans cover colorectal cancer screening tests. 

Specifically, we determined 

1. 	 the extent to which state laws require private health insurance plans to 

cover the four colorectal cancer tests for screening purposes; and 

2. 	 the extent to which private health insurance plans cover the four 

colorectal cancer tests for screening purposes, specifically health 

plans 

• sold by insurers to small employers and individuals in states that do not 

require such coverage, 

• offered by large employers across the United States, and 

• offered through the Federal Employees Health Benefits Program 

(FEHBP).

3 

To identify states that had laws that require private health insurance plans 

to cover colorectal cancer screening tests, we reviewed the laws in each 

state and the District of Columbia as of May 2004, and consulted with state 

officials to clarify the laws as necessary.4

 To examine the extent to which 

health insurance plans sold to small employers and individuals by insurers 

in the states without laws requiring coverage of the tests actually covered 

the tests, we contacted the largest health insurers in 10 states without 

such laws. From these insurers we obtained information from plan 

representatives about their coverage policies for their health plan with the 

most members. We received responses to our questions from 95 percent 

(18 of 19) of the small employer insurers we contacted and 82 percent (14 

of 17) of the individual insurers we contacted.5

 To examine the extent to 

which health plans offered by large employers covered the tests for 

screening purposes, we randomly selected 50 large employers from 

Fortune 500 companies throughout the United States and received 

2

Most recently introduced were S. 2265, 108th Cong. (2004) and H.R. 4097, 108th Cong. 

(2004). 

3

Through FEHBP, the federal government provides group health insurance coverage to its 

employees through participating private health insurance carriers. 

4

Throughout the remainder of this report, the District of Columbia is included as a state. 

5

Although 18 small employer insurers responded, we report results from 19 small employer 

plans because the colorectal cancer screening benefits for 1 plan differed for two benefit 

packages. 

Page 2 GAO-04-713 Colorectal Cancer Screening Test Coverage 
responses from 71 percent (35 of 49) of the employers we contacted.6

 We 

relied on self-reported information from officials of the health plans 

reviewed and did not independently verify their responses. Further, 

although we achieved relatively high response rates, we may nonetheless 

have encountered selection bias. That is, insurers and large employers 

with more colorectal cancer screening benefits could have been more 

likely to participate in our survey than those with fewer colorectal cancer 

screening test benefits. In addition, we surveyed a small number of health 

plans, precluding our ability to generalize the findings beyond these plans. 

Finally, to examine the extent to which health plans offered through 

FEHBP covered the four tests for screening purposes, we reviewed 

coverage brochures for 143 plans maintained on the Office of Personnel 

Management’s (OPM) Web site.

7,8 We identified the extent to which each 

brochure explicitly indicated coverage of each of the four tests for 

screening purposes. In addition, we clarified our understanding of the 

brochures with OPM staff and confirmed our interpretations of selected 

brochures with plan representatives. 

We conducted our work from October 2003 through June 2004 according 

to generally accepted government auditing standards. Appendix I provides 

additional details about our scope and methodology. 

Twenty states had laws in place as of May 2004 requiring private health 

insurance plans to cover colorectal cancer tests for screening purposes.

9

 In 

19 of these states, the laws generally applied to group and individual 

health plans sold by health insurers, and required coverage of four 

colorectal cancer tests for screening purposes—FOBT, flexible 

sigmoidoscopy, DCBE, and colonoscopy—typically consistent with ACS 

guidelines. The law in 1 of the states was more limited in scope, applying 

6

One company was later removed from the sample because it no longer had employees in 

the United States at the time we conducted our work. 

7

OPM serves as the federal government’s human resource agency and administers FEHBP. 

8

When a FEHBP plan’s brochure offered multiple benefit options, we counted each option 

as a separate plan. When a plan was offered in multiple locations but with the same 

benefits, we counted it as one plan. Our review of 2004 FEHBP brochures identified 143 

distinct health benefit plans. 

9

These state laws apply primarily to coverage sold by insurers, and thus largely affect plans 

sold to small employers and individuals. Self-funded plans are not typically subject to state 

insurance regulation. 

Results in Brief 

Page 3 GAO-04-713 Colorectal Cancer Screening Test Coverage 
to group and managed care plans and not explicitly requiring coverage of 

each of the four screening tests according to ACS guidelines. 

Among the health insurance plans we reviewed that were sold to small 

employers and individuals in states without laws requiring coverage of 

colorectal cancer screening tests, offered by large employers, and offered 

through FEHBP, we found the majority covered all four colorectal cancer 

screening tests. However, some plans we reviewed covered fewer than 

four of the tests or none at all, including about 16 percent of the small 

employer, 29 percent of the individual, and 31 percent of the large 

employer plans. Among plans that covered some, but not all, tests, DCBE 

and colonoscopy were least likely to be covered. In particular: 

• 	 In 10 states without laws requiring private health insurance coverage of 

colorectal cancer screening tests, most small employer and individual 

plans we reviewed provided coverage for all four screening tests. 

However, 3 of 19 small employer plans did not cover all four tests and 4 of 

14 individual plans covered none of the tests. 

• 	 Similarly, most of the large employer plans we reviewed covered all four 

colorectal cancer screening tests. Among 11 of 35 plans that did not, 7 

covered FOBT or flexible sigmoidoscopy and 4 covered none of the tests. 

• 	 Most FEHBP plans covered all four colorectal cancer tests for screening 

purposes. For example, among the 17 national plans that are offered to 

federal employees, retirees, and their dependents across the United States, 

12 covered all four tests for screening purposes, and 5 covered all tests 

except DCBE. 

In commenting on a draft of this report, ACS suggested that the report 

overstated the extent of coverage, and that the report did not sufficiently 

highlight the methodological limitations of the study. In contrast, 

America’s Health Insurance Plans (AHIP) commented that the report 

overstated the lack of coverage. In addition, AHIP commented that the 

report did not address the low rate at which Americans actually receive 

colorectal cancer screening tests regardless of health insurance coverage, 

which it said suggests that insurance coverage of the tests is not 

responsible for the low screening rates. Recognizing that our findings are 

subject to varying interpretations, we attempted to report them neutrally 

and to not overly emphasize the coverage that did or did not exist. 

Although the draft report disclosed the methodological limitations of the 

study, in response to ACS comments, we revised the report to more 

prominently highlight certain limitations. Finally, the draft report noted 

the rates at which Americans receive colorectal cancer screening tests as 

Page 4 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Background 

part of the background; however, further assessing the factors responsible 

for the service utilization was beyond the scope of this study. 

Surviving colorectal cancer is greatly enhanced when the disease is 

detected and treated early; however, only 38 percent of colorectal cancer 

cases are diagnosed at an early stage, according to ACS.10 To facilitate 

early diagnosis, ACS recommends regular colorectal cancer screening for 

certain individuals using at least one of four key tests: FOBT, flexible 

sigmoidoscopy, DCBE, and colonoscopy. These tests are used to find 

potential signs of colorectal cancer, including polyps—abnormal growths 

in a person’s colon—or blood in a person’s stool. FOBT is a laboratory test 

used to detect blood (that is otherwise not visible) in stool samples that 

are collected by patients at home. Using a flexible sigmoidoscopy, a 

physician can find and take samples of polyps in a patient’s lower colon 

and rectum. DCBE detects polyps by providing x-ray images of a patient’s 

entire rectum and colon. Finally, a colonoscopy allows a physician to find 

and take samples of polyps in a patient’s rectum and entire colon as well 

as remove most polyps found during the test.

11 

ACS, medical providers, and others have developed medical guidelines 

that outline the frequency at which colorectal cancer screening tests 

should be administered depending on an individual’s age and risk for 

developing the disease. For example, ACS guidelines recommend that, 

beginning at age 50, all average-risk individuals be screened annually using 

an FOBT; every 5 years using a flexible sigmoidoscopy or DCBE; or every 

10 years using a colonoscopy. ACS guidelines also state that a combination 

of both FOBT and flexible sigmoidoscopy at the intervals indicated is the 

preferred screening method over either test alone, and that individuals at 

high or increased risk for developing the disease should be screened more 

frequently.12 Furthermore, ACS believes that patients and providers should 

10American Cancer Society, Cancer Facts and Figures, 2004 (Atlanta, Ga.: 2004). 

11In 2001, the most current year for which data were available, the Centers for Disease 

Control and Prevention (CDC) estimated that a FOBT cost between $10 and $25; a flexible 

sigmoidoscopy cost between $150 and $300; a DCBE cost between $250 and $500; and a 

colonoscopy cost between $800 and $1600. “Health Professionals Facts on Screening,” 

Cancer Prevention and Control, Centers for Disease Control and Prevention. 

http://www.cdc.gov/cancer/screenforlife/fs_professional.htm (downloaded Mar. 17, 2004). 

12ACS accepts the Medicare program definition for a high-risk individual: someone who, 

because of family history, prior experience of cancer, or other predisposing factors for the 

disease, faces a high risk for colorectal cancer. ACS defines an individual with an average 

risk for colorectal cancer as someone who does not fall into the high-risk category. 

Page 5 GAO-04-713 Colorectal Cancer Screening Test Coverage 
jointly choose the appropriate tests and testing strategy based on patient 

risk factors and the varying accuracy, cost, and discomfort of the tests, 

among other factors. ACS’s colorectal cancer screening guidelines are also 

similar to those endorsed by the American Gastroenterological 

Association and the American Medical Association. The Medicare program 

covers all four screening tests following guidelines similar to those 

developed by ACS.13 The United States Preventive Services Task Force 

(USPSTF) also strongly recommends that clinicians screen men and 

women 50 years of age or older for colorectal cancer. However, it specifies 

the frequency with which tests should be administered only for FOBT, for 

which annual testing is suggested.

14 Similar to ACS, USPSTF recommends 

that the choice of tests and testing strategy be based on a variety of factors 

including patient preferences and medical contraindications. 

Fewer than half of individuals age 50 and over surveyed in a 2002 national 

study reported receiving a colorectal cancer test for screening or 

diagnostic purposes. FOBT was used by approximately 45 percent of 

respondents age 50 and over, with less than half of these respondents 

having had their last test within the past year. The survey also found that a 

sigmoidoscopy or colonoscopy test was used by just under 50 percent of 

respondents age 50 and over at some point in their lives.

15 Reasons that 

13In 2002, over 40 million individuals received health care coverage through Medicare—the 

federal health insurance program that serves adults over age 65, certain persons with 

disabilities, and people with end stage renal disease. Prior to January 1, 1998, Medicare 

covered each of the four tests only for the diagnosis and treatment of colorectal cancer. 

The Balanced Budget Act of 1997 expanded Medicare coverage to include colorectal cancer 

tests for screening purposes. Medicare’s coverage guidelines indicate a patient must be at 

least 50 years old for all tests except colonoscopy, for which there is no minimum age 

requirement. Generally, Medicare covers a FOBT annually, a flexible sigmoidoscopy once 

every 4 years, and a colonoscopy once every 10 years. Patients at high risk for developing 

colorectal cancer are covered for a colonoscopy once every 2 years. Medicare also covers a 

DCBE in place of a flexible sigmoidoscopy or a colonoscopy once every 4 years or—for 

high-risk individuals—once every 2 years. 

14USPSTF is an independent panel of private medical experts that evaluates the merits of 

clinical research and issues recommendations on preventive measures. The U.S. 

Department of Health and Human Services, Agency for Healthcare Research and Quality 

sponsors USPSTF. 

15GAO analysis of the “Behavioral Risk Factor Surveillance System Online Prevalence Data, 

1995-2002,” Division of Adult and Community Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. 

http://apps.nccd.cdc.gov/brfss (downloaded Apr. 26, 2004). The Behavioral Risk Factor 

Surveillance System is sponsored by CDC and is conducted by individual states and 

territories. In 2002, almost 250,000 adults were surveyed. Our analysis excluded data from 

California because it included respondents under 50 years of age. 

Page 6 GAO-04-713 Colorectal Cancer Screening Test Coverage 
individuals do not obtain a colorectal cancer screening test may include a 

lack of patient education, a general reluctance to be tested, or a 

physician’s lack of time to discuss or educate patients about screening.16 

Private health insurance is offered in two primary markets—the group and 

individual markets. The group market includes health plans offered by 

employers to employees. An employer may provide coverage for its 

employees either by purchasing the coverage from a health insurer (fully 

insured coverage) or by funding its own health plan (self-funded 

coverage). Within the group market, small employers typically purchase 

coverage from insurers, while larger employers are more likely to self-fund 

their coverage.17 Although the federal government is a large employer— 

with over 2.7 million employees in 2002—it provides health coverage for 

its employees through health insurance carriers that participate in 

FEHBP.18 About 161 million individuals received health coverage from the 

group market in 2002.19 The individual market includes health plans sold 

by insurers to individuals who do not receive coverage through an 

employer. About 16.8 million Americans received health coverage from the 20 individual market in 2002. 

Private health plans are subject to various state and federal requirements, 

depending upon the market segments in which they are offered and the 

manner in which the plans are funded. The fully insured health coverage 

offered by small employers is subject to state insurance requirements, 

which can include mandated coverage for preventive health services and 

16See U.S. General Accounting Office, Medicare: Few Beneficiaries Use Colorectal Cancer 

Screening and Diagnostic Services, GAO/T-HEHS-00-68 (Washington, D.C.: Mar. 6, 2000) 

and J.M.E. Walsh and J.P. Terdiman, “Colorectal Cancer Screening, Clinical Applications,” 

The Journal of the American Medical Association, vol. 289, no. 10 (2003). 

17States typically define small groups as those with fewer than 100 employees for purposes 

of establishing regulations that apply to health plans in the small group market. 

18FEHBP offers plans to all enrollees who may work anywhere in the country, referred to 

as national plans. Other plans offered only in certain local markets are referred to as local 

plans. In 2003, over 8 million enrollees and their dependents were covered under FEHBP 

plans—about 70 percent and 30 percent in the national and local plans, respectively. 

19P. Fronstin, “Sources of Health Insurance and Characteristics of the Uninsured: Analysis 

of the March 2003 Current Population Survey,” Employee Benefits Research Institute, 

Issue Brief Number 264 (December 2003). 

20Fronstin, “Sources of Health Insurance and Characteristics of the Uninsured: Analysis of 

the March 2003 Current Population Survey.” 

Page 7 GAO-04-713 Colorectal Cancer Screening Test Coverage 
other benefits.

21 Individual market coverage purchased by individuals from 

insurers is also subject to state insurance requirements. The self-funded 

coverage typically offered by larger employers is generally not subject to 

state insurance regulation, but only to federal requirements, none of which 

are related to preventive health services.

22 

OPM is responsible for regulating, and contracting with, private health 

insurers to offer health benefit plans to federal employees, pursuant to the 

Federal Employees Health Benefits Act.23 While private health insurers are 

generally subject to the applicable laws in their respective states, by 

federal law, the terms of any FEHBP contract negotiated by OPM, which 

relate to coverage or benefits, preempt any inconsistent state or local law 

or regulation.24 To assure a consistent set of benefits among the national 

plans, OPM routinely preempts state regulation, but generally does not do 

so for the local plans, according to an OPM official. 

21For example, almost all states have a mandate requiring coverage for mammography 

screening and about half of the states have mandates requiring prostate and cervical cancer 

screening coverage. See U.S. General Accounting Office, Private Health Insurance: 

Federal and State Requirements Affecting Coverage Offered by Small Businesses, 

GAO-03-1133 (Washington, D.C.: Sept. 30, 2003). 

22The Employee Retirement Income Security Act of 1974 (ERISA) preempts state law as it 

may relate to an employee benefit plan. See 29 U.S.C. § 1144(a)(2000). However, ERISA 

preserves state laws which regulate insurance from preemption. See 29 U.S.C. § 

1144(b)(2)(A). Federal law also establishes several requirements for private health 

insurance plans that apply to both fully insured and self-funded coverage, such as certain 

portability and minimum benefit requirements. For example, the Health Insurance 

Portability and Accountability Act protects health insurance coverage for workers and their 

families under certain specified conditions, such as a change in employment. See 29 U.S.C. 

§ 1181. The Mental Health Parity Act requires employers with more than 51 employees to 

provide coverage for mental health services under the same terms and conditions applied 

to other medical conditions. See 42 U.S.C. § 300gg-5. The Newborns’ and Mothers’ Health 

Protection Act of 1996 provides that health care plans and insurers may not restrict 

benefits for a childbirth-related hospital stay to less than 48 hours (or 96 hours following a 

caesarean section delivery). See 42 U.S.C. § 300gg-4. The Women’s Health and Cancer 

Rights Act requires health plans and insurers that provide medical and surgical benefits for 

mastectomies to provide coverage for reconstructive surgery. See 29 U.S.C. § 1185b. 

235 U.S.C. §§ 8901-14(2000). 

245 U.S.C. § 8902(m)(1). 

Page 8 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Twenty States Had 

Laws That Require 

Private Health 

Insurance Plans to 

Cover Colorectal 

Cancer Screening 

Tests 

Twenty states had laws requiring private health insurance plans to cover 

colorectal cancer screening tests as of May 2004. In 19 of these states, the 

laws generally applied to group or individual health plans, and required 

coverage of all four tests—FOBT, flexible sigmoidoscopy, DCBE, and 

colonoscopy—typically consistent with ACS guidelines. However, the law 

in Wyoming had limitations. It was more limited in scope, applying to 

group and managed care plans and not explicitly requiring coverage of 

each of the four screening tests according to ACS guidelines. Table 1 

shows the scope of state laws and appendix II provides a detailed 

summary of each of the 20 state laws. 

Table 1: State Laws Requiring Private Insurance Coverage of Colorectal Cancer 

Screening Tests 

Scope of state laws States Number of states 

Apply to fully insured group or California, Connecticut, Delaware, 

individual plans and screening 

test coverage according to 

ACS guidelines 

District of Columbia, Georgia, 

Illinois, Indiana, Maryland, 

Minnesota, Missouri, New Jersey, 

Nevada, North Carolina, 

Oklahoma, Rhode Island, 

Tennessee, Texas, Virginia, West 

Virginia 

Applied to group and managed Wyoming


care plans, and did not specify


coverage of each test in


accordance with ACS 


guidelines 


Total 

Majority of Health 

Plans Reviewed 

Covered the Four 

Colorectal Cancer 

Screening Tests 

Source: GAO analysis of state laws. 

The majority of health insurance plans we reviewed provided coverage for 

the four key colorectal cancer screening tests. These included health plans 

that were sold to small employers and individuals in states without laws 

requiring colorectal cancer screening coverage, were offered by large 

employers across the United States, and were offered to federal employees 

through FEHBP. Among plans that covered fewer than four of the tests, 

DCBE and colonoscopy were least likely to be covered. 

Page 9 GAO-04-713 Colorectal Cancer Screening Test Coverage 

19 

1 

20 
In States Without 

Colorectal Cancer 

Screening Test Laws, Most 

of the Small Employer and 

Individual Plans Reviewed 

Provided Coverage for All 

Four Tests 

In 10 states without laws requiring private health insurance coverage of 

colorectal cancer screening tests, most of the small employer plans we 

reviewed—16 of 19—covered all four colorectal cancer screening tests. 

The remaining 3 plans covered FOBT or FOBT and flexible 

sigmoidoscopy, but not DCBE or colonoscopy. Among the 14 individual 

plans we reviewed, 10 covered all four colorectal cancer tests for 

screening purposes. The remaining 4 plans did not offer screening 

coverage for any of the tests. (See table 2.) 

Table 2: Coverage of Colorectal Cancer Screening Tests Among 19 Small Employer 

and 14 Individual Health Plans Reviewed in 10 States 

Plan coverage of specified tests 

Tests covered Number Percentage 

Small employer insurers 

All four tests 16 

FOBT and flexible sigmoidoscopy only 1 

FOBT only 2 

Total plans reviewed 19 

Individual insurers 

All four testsa 10 

None of the four tests 4 

Total plans reviewed 14 

Source: GAO analysis of data provided by insurers. 

a

One plan placed an annual limit of $300 on all preventive health services. This limit could preclude 

full reimbursement for a DCBE or colonoscopy. 

Most Large Employer 

Plans Reviewed Covered 

All Four Colorectal Cancer 

Screening Tests 

Twenty-four of the 35 large employer plans we reviewed, or approximately 

two-thirds of these plans, covered all four colorectal cancer tests for 

screening purposes. Seven of the 35 plans covered only one of the 

colorectal cancer screening tests: FOBT or flexible sigmoidoscopy. 

Neither DCBE nor colonoscopy was covered by any of the large employer 

plans that provided limited test coverage. Four of the health plans offered 

by the large employers did not cover any of the colorectal cancer tests for 

screening purposes. (See table 3.) 

Page 10 GAO-04-713 Colorectal Cancer Screening Test Coverage 

84 

5 

11 

100 

71 

29 

100 
Table 3: Coverage of Colorectal Cancer Screening Tests Among Health Plans 

Offered by 35 Large Employers Reviewed 

Plan coverage of specified tests 

Tests covered Number Percentage 

All four testsa 24 

FOBT only 5 

Flexible sigmoidoscopy only 2 

None of the four tests 4 

Total plans reviewed 35 

Source: GAO analysis of data provided by large employers. 

a

One plan places an annual limit of $500 on all preventive health services. This limit could preclude 

full reimbursement for a colonoscopy. 

Over Half of FEHBP Plans Seventy-seven of the 143 FEHBP plans covered all four screening tests for 

Covered All Four colorectal cancer in 2004.

25 Among the 17 national FEHBP plans, 12 

Colorectal Cancer covered all four tests, and 5 covered FOBT, flexible sigmoidoscopy, and 

colonoscopy, but not DCBE. (See table 4.) About 70 percent of the over 8 Screening Tests 

million FEHBP enrollees and their dependents were covered through the 

national plans in 2003. 

Table 4: Coverage of Colorectal Cancer Screening Tests Among 17 National FEHBP 

Plans 

Plan coverage of specified 

tests 

Tests covered Number Percentage 

All four tests 12 71 

FOBT, flexible sigmoidoscopy, and colonoscopy only 5 29 

Total plans reviewed 17 100 

Source: GAO analysis of 2004 FEHBP plan coverage. 

25In 2002 and 2003, OPM encouraged insurers to consider covering all four of the colorectal 

cancer screening tests. 

Page 11 GAO-04-713 Colorectal Cancer Screening Test Coverage 

69 

14 

6 

11 

100 
External Comments 


and Our Evaluation 


Among the 126 local FEHBP plans, 65 plans either provided coverage for 

the four colorectal cancer screening tests as confirmed through a review 

of their brochures or follow-up with selected plan officials, or were 

located in states that required this coverage. The brochures for the 

remaining 61 plans indicated coverage of at least FOBT and flexible 

sigmoidoscopy, but did not explicitly identify whether the additional tests 

were covered for screening purposes. According to an OPM official, plans 

may cover tests that are not explicitly referenced in the brochures. We 

contacted 8 local plans and confirmed that brochure language was not 

definitive. According to the plan representatives, each of the 8 plans 

covered at least one test in addition to the two specified in the brochure. 

Representatives of ACS and AHIP provided comments on a draft of this 

report. ACS commented that the report overstates coverage, for example 

by stating that coverage is common or by not placing greater emphasis on 

plans that covered few or none of the colorectal cancer tests for screening 

purposes. In contrast, AHIP commented that the report overstates the lack 

of coverage, for example by highlighting the number of plans that covered 

fewer than four tests rather than the number of plans that covered at least 

one test. Recognizing that our findings are subject to varying 

interpretations, we attempted to report them neutrally and to not overly 

emphasize the coverage that did or did not exist. ACS and AHIP also 

commented on the scope of our report and limitations to our study 

methods, as discussed below, and provided technical comments, which we 

incorporated as appropriate. 

ACS Comments 
 ACS suggested that we did not sufficiently address several methodological 

limitations in our report. In particular, ACS stated that we used small 

samples, did not conduct an analysis of nonrespondents, surveyed only the 

health plans with the most members where insurers or employers offered 

more than one plan, and did not independently verify the responses of the 

insurers and employers we contacted. We agree that our study methods 

are subject to limitations, which we disclosed in our draft report. We 

reviewed samples of health plans that would provide credible evidence of 

coverage levels in each market segment, recognizing that the results would 

not be generalizable to all health plans. While we believe our relatively 

high response rates of between 71 and 95 percent diminished the need for 

a detailed analysis of nonrespondents, we acknowledged the possibility of 

selection bias in the draft report. Similarly, although we did not examine 

every plan offered by each insurer and employer, we focused on those 

plans that covered the greatest number of enrollees to best illustrate the 

Page 12 GAO-04-713 Colorectal Cancer Screening Test Coverage 
coverage most widely available to consumers. In terms of verifying survey 

responses, we did not have ready access to the documents that could have 

provided verification of employer and insurer responses to our questions. 

Insurer underwriting manuals may provide such verification, but are 

considered proprietary by insurers and not shared externally. Documents 

readily available to us, such as plan brochures, do not indicate coverage of 

every medical test or procedure under every possible circumstance, and 

thus could not be used to verify insurer or employer responses to our 

questions. Our draft report noted that we did not independently verify 

reported responses. In response to ACS’s comments that we did not 

sufficiently address our study limitations, we modified the final report to 

more prominently highlight certain limitations of our methodology. 

ACS further commented that we did not highlight the differences between 

the higher coverage rates we found based on the self-reported data 

provided by employers and insurers and the lower coverage rates we 

found based on our review of FEHBP brochures, suggesting that the 

differences indicate the potential for self-reported data to overstate plan 

coverage. As the draft report noted, we found that FEHBP brochures did 

not specify every medical test or procedure covered under every 

circumstance and thus the brochures may understate coverage actually 

available. This fact was confirmed by several plan and OPM officials and is 

consistent with our own previous reviews of health plan brochures. 

Among the 17 national plans, for which we were able to follow up with 

plan officials in each instance where the brochure language was not 

exhaustive, most covered tests not mentioned in their brochures. 

Moreover, through our follow-up with eight local plans we determined that 

each plan covered at least one test in addition to those listed in their 

brochures. 

ACS also commented that we did not assess the quality of prior studies of 

colorectal cancer screening coverage rates and consider the study results 

in our report. While our draft report acknowledged that prior studies have 

been conducted, we did not elaborate on them because, as ACS noted, 

each was subject to certain limitations. Evaluating the quality of prior 

studies was beyond the scope of our work. 

AHIP Comments 	 AHIP commented that the draft report did not sufficiently address the low 

rate at which Americans actually receive colorectal cancer screening tests 

in spite of relatively high coverage rates among health plans, suggesting 

that factors other than insurance coverage are responsible for the low 

screening rate. The draft report’s background section noted colorectal 

Page 13 GAO-04-713 Colorectal Cancer Screening Test Coverage 
cancer screening rates and certain factors cited by other researchers that 

influence these rates. However, an assessment of the factors influencing 

screening utilization rates, beyond the extent of health insurance 

coverage, was outside the scope of this report. 

AHIP also suggested that the report include a discussion of the factors that 

drive the benefit package decisions made by employers and consumers in 

selecting health plans, noting that such decisions are necessarily 

influenced by cost, individual circumstances, and other factors. We agree 

that many factors influence the choice of benefits consumers or employers 

select when choices are available, but examining these factors was beyond 

the scope of this study. 

AHIP further commented that we emphasized the ACS colorectal cancer 

screening guidelines, but not those set forth by USPSTF, which they 

suggested are also highly regarded. We used the ACS guidelines as a 

complete framework for presenting our findings because the guidelines 

indicate a frequency for each test. While USPSTF guidelines include the 

four tests specified by ACS, they only indicate the frequency with which 

the tests should be administered for FOBT. Nevertheless, we modified the 

report to add reference to the USPSTF guidelines. 

As agreed with your office, unless you publicly announce its contents


earlier, we plan no further distribution of this report until 30 days after its 


issue date. At that time, we will send copies to interested congressional


committees and members and make copies available to others upon 


request. In addition, the report will be available at no charge on the GAO 


Web site at http://www.gao.gov. 


Please contact me at (202) 512-7118 or Randy DiRosa at (312) 220-7671 if 


you or your staff have any questions. Key contributors to this report are 


listed in appendix III.


Sincerely yours, 


Kathryn G. Allen 


Director, Health Care—Medicaid 


and Private Health Insurance Issues 


Page 14 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Appendix I: Scope and Methodology 


To examine the extent to which the four key colorectal cancer tests are 

covered for screening purposes by private health insurance plans, we 

reviewed the extent to which state laws require such coverage, and we 

reviewed the extent of coverage among selected small employer and 

individual plans in states without such laws, a sample of large employer 

plans, and coverage within FEHBP plans. We conducted our work from 

October 2003 through June 2004 according to generally accepted 

government auditing standards. 

State Laws Requiring To identify states that had laws that require private health insurance plans 

Colorectal Cancer to cover colorectal cancer screening tests, we reviewed the laws in each 

Screening Test Coverage state as of May 2004, and consulted with state officials to clarify the laws 

as necessary. We did not include state regulations or policies applicable to 

insurance plans in our review. 

Small Employer and 

Individual Health Plans 

To examine coverage of colorectal cancer screening tests in small 

employer and individual health plans, we identified the largest health 

insurers in 10 of the states without existing or pending colorectal cancer 

screening laws by using information compiled by CDC, the National 

Association of Insurance Commissioners, Blue Cross and Blue Shield 

Association, and the National Conference of State Legislatures. This 

assessment was completed in November 2003.1

 We selected five states 

based on their large population—Florida, Massachusetts, Michigan, New 

York, and Wisconsin—and randomly chose five additional states— 

Arizona, Arkansas, Colorado, Louisiana, and Maine.2 To identify the largest 

health insurers in these states, we contacted insurance regulators in each 

state and asked them to identify the two largest small employer health 

insurers and the two largest individual health insurers in terms of covered 

lives, premiums collected, or—in the absence of quantitative data—their 

best judgment.

3 

1

We excluded states that had laws requiring coverage of colorectal cancer screening tests 

because determining insurer compliance with state laws was beyond the scope of this 

study. 

2

We excluded states with pending legislation from our sample in the event that the state 

passed the legislation during the course of our work. 

3

Insurance regulators reported that a small employer plan in one state and an individual 

plan in two states covered at least two-thirds of the market in these states. We reviewed 

only these plans for that particular market and state. 

Page 15 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Appendix I: Scope and Methodology 

We contacted the insurers identified to obtain information about the 

extent to which their health plan with the most members covered 

colorectal cancer screening tests. We posed a series of questions related to 

insurers’ coverage of four colorectal cancer tests—FOBT, flexible 

sigmoidoscopy, DCBE, and colonoscopy—for screening purposes.4 

Further, we asked insurers about their health plans’ coverage restrictions, 

including those related to age, frequency, family history, personal history, 

and plan authorization. We received responses to our questions from 18 of 

the 19 small employer insurers we contacted (95 percent), and 14 of the 17 

individual insurers we contacted (82 percent).5 

Large Employer Health 

Plans 

To examine coverage of colorectal cancer screening tests in large 

employer health plans, we randomly selected 50 companies from the 2002 

Fortune 500 list.

6 One company was subsequently removed from the 

sample because it filed for bankruptcy protection after the list was 

published and no longer had any U.S. employees. Thus, the final sample 

included 49 companies. We contacted health plan benefits administrators 

or human resources staff in each of these companies. We made at least 

three attempts to obtain a response from each company in our sample, 

including contacting the company’s government affairs or chief executive 

office to request participation in certain instances. Similar to insurers 

offering small employer and individual health plans, participating 

employers answered questions related to their largest plan’s coverage of 

the four key colorectal cancer tests for screening purposes and 

restrictions related to this screening test coverage. We received responses 

from 35, or 71 percent, of the companies we contacted. 

4

We considered coverage for screening purposes to include coverage for people who do not 

exhibit signs of colorectal cancer and do not have a family or personal history of the 

disease. 

5

In 2 plans offered to individuals and 2 offered to small employers, some colorectal cancer 

screening tests were covered through the health plans’ preventive care rider that provided 

coverage in addition to the basic health plan benefits. In our analysis of these plans, we 

included coverage information for the subsection of the plan—either with or without the 

rider—that included the majority of the plan’s members. In addition, for 1 of the plans 

offered to small employers, half of the plan members had the rider that provided coverage 

of colorectal cancer screening tests, and half did not. The information for both subsections 

of the plan—with and without the rider—was included in our results as representing 2 

separate plans. Thus we received responses from 18 of the small employer insurers we 

contacted but report results for 19 plans. 

6

“Fortune 5 Hundred Largest U.S. Corporations,” Fortune, Vol. 147, No. 7 (2003). All the 

companies on this list have over 100 employees. 

Page 16 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Appendix I: Scope and Methodology 

Three plans offered by large employers reported covering one or more of 

the four colorectal cancer tests for screening purposes, but also required 

that a member have a family or personal history of the disease in order to 

receive coverage for the screening test. Because these requirements were 

inconsistent with our definition of screening test coverage, we 

characterized these plans as not covering the relevant tests for screening 

purposes. 

FEHBP Plans 	 To identify coverage policies of health plans offered through FEHBP, we 

reviewed 2004 coverage brochures maintained on the OPM website. When 

a plan offered multiple benefit options, we counted each option as a 

separate plan. When the same plan was offered in multiple locations but 

with the same benefits, we counted it as one plan. Our review of 2004 

FEHBP brochures identified 143 distinct benefit plans. We identified the 

extent to which each of the four tests was explicitly listed as a covered 

benefit for screening purposes for each plan. We then discussed our 

interpretation of the brochure language with OPM representatives. In 

addition, we contacted representatives of each of the 5 national plans and 

8 of the 61 local plans whose brochures did not explicitly indicate the 

coverage of each of the four tests. The local plans were selected 

judgmentally from different geographic areas of the country. We discussed 

with plan officials our interpretation of their brochure language, and 

revised our analysis based on these discussions. 

Limitations 
 We relied on self-reported information from officials of the health plans 

offered to small employers, individuals, and large employers, and did not 

independently verify their responses. Further, although we achieved 

relatively high response rates of between 71 and 95 percent for our review 

of coverage in the small employer, individual, and large employer market 

segments, we may nonetheless have encountered selection bias. That is, 

insurers and large employers with more colorectal cancer screening 

benefits could have been more likely to participate in our survey than 

those with fewer colorectal cancer screening test benefits. In addition, we 

surveyed a small number of small employer, individual, and large 

employer health plans, precluding our ability to generalize the findings 

beyond these health plans. Nevertheless, our findings illustrate the 

colorectal cancer screening test benefits of approximately 4 million 

individuals covered under the small employer, individual, and large 

employer plans we reviewed, and more than 8 million individuals covered 

under FEHBP. 

Page 17 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Appendix II: State Laws Requiring Private 

Health Insurance Coverage of Colorectal 

Cancer Screening Tests 

Table 5 shows state colorectal cancer screening laws in place as of May 

2004. As indicated, 20 states have laws that require private insurance 

coverage of colorectal cancer screening tests. 

Table 5: State Colorectal Cancer Screening Laws for Private Health Insurance 

State Law generally applies to group/individual Law generally requires coverage consistent 

(Date enacted) health plans unless otherwise noteda with ACS guidelines unless otherwise notedb 

California (2000) Yes Generally medically accepted cancer screening 

tests 

Connecticut (2001) Yes Yes 

District of Columbia (2002) Yes Yes 

Delaware (2001) Yes 	 Fecal occult blood test (FOBT), flexible 

sigmoidoscopy, colonoscopy, double-contrast 

barium enema (DCBE), or any combination of the 

most reliable, medically recognized screening 

tests, as determined by the state 

Georgia (2002) Yes Yes 

Illinois (2004) Yes Yes 

Indiana (2000) Yes Yes 

Maryland (2001) Yes Yes 

Minnesota (1988) Yes Routine screens 

Missouri (1999) Yes Yes 

Nevada (2003) Yes Yes 

New Jersey (2002) Yes Yes 

North Carolina (2002) Yes Yes 

Oklahoma (2002) Yesc Accepted published medical guidelines 

Rhode Island (2000) Yes Yes 

Tennessee (2004) Yesd Yes 

Texas (2002) Yese Yes 

Virginia (2000) Yes Yes 

West Virginia (2000) Yesf Yes 

Wyoming (2001) Group or blanket disability policies and Colorectal cancer tests 

managed care contractsg 

Source: GAO analysis of state laws. 

a

State laws may also apply to other market segments, such as health plans for public sector 

employees. 

b

Some state laws require coverage of more than the four tests specified by ACS, or indicate other 

guidelines in addition to ACS. 

c

Does not include groups with fewer than 50 employees. 

d

Plans are required to offer coverage of colorectal cancer tests as an optional benefit. 

Page 18 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Appendix II: State Laws Requiring Private 

Health Insurance Coverage of Colorectal 

Cancer Screening Tests 

e

Plans are required to offer coverage of colorectal cancer screening tests if they provide coverage for 

screening medical procedures. 

f

Applies to plans providing coverage for laboratory and x-ray services. 

g

The statute covers all group and blanket disability insurance policies providing coverage on an 

expense incurred basis, group service or indemnity type contracts issued by a non-profit corporation, 

group service contracts issued by a health maintenance organization, all self-insured group 

arrangements to the extent not preempted by federal law, and all managed health care delivery 

entities of any type or description. 

Page 19 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact Randy DiRosa, (312) 220-7671 

Acknowledgments 	 Susan Anthony, Christine DeMars, Iola D’Souza, Sari B. Shuman, and Behn 

M. Kelly made key contributions to this report. 

Page 20 GAO-04-713 Colorectal Cancer Screening Test Coverage 
Related GAO Products 


Private Health Insurance: Federal and State Requirements Affecting 

Coverage Offered by Small Businesses. GAO-03-1133. Washington, D.C.: 

September 30, 2003. 

Medicare: Most Beneficiaries Receive Some but Not All Recommended 

Preventive Services. GAO-03-958. Washington, D.C.: September 8, 2003. 

Medicare: Use of Preventive Services is Growing but Varies Widely. 

GAO-02-777T. Washington, D.C.: May 23, 2002. 

Medicare: Beneficiary Use of Clinical Preventive Services. GAO-02-422. 

Washington, D.C.: April 12, 2002. 

Medicare: Few Beneficiaries Use Colorectal Cancer Screening and 

Diagnostic Services. GAO/T-HEHS-00-68. Washington, D.C.: March 6, 2000. 

(290332) Page 21 GAO-04-713 Colorectal Cancer Screening Test Coverage 
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