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. 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. 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. Furthermore, ACS believes that patients and providers should 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. 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. 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. Reasons that 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. 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. 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. About 161 million individuals received health coverage from the group market in 2002. 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 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 other benefits. 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. 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. 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. 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. 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. 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. 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.) 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.) Seventy-seven of the 143 FEHBP plans covered all four screening tests for colorectal cancer in 2004. Among the 17 national FEHBP plans, 12 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 million FEHBP enrollees and their dependents were covered through the national plans in 2003. 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 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.