State Medicaid Coverage for Lung Cancer Screening Is Spotty

Roxanne Nelson, RN, BSN

April 17, 2019

Screening can reduce mortality from lung cancer by catching the disease early, but coverage is still uneven, despite the green light given by the US Preventive Services Task Force (USPSTF) in 2013.

Although Medicare and most private insurers will reimburse for low-dose computed tomography (LDCT) in eligible high-risk patients, screening is not universally covered by Medicaid. According to a new report by the American Lung Association (ALA), 31 Medicaid fee-for-service programs cover lung cancer screening, 12 programs do not provide coverage, and seven states lack available information on their coverage policy. The analysis also found that Medicaid programs vary in the eligibility criteria they use for screening as well as whether they require prior authorization.

“We are working to educate state-level decision makers on where there are gaps in coverage,” said Hannah Green, MPH, National Director of Health Policy, ALA. The ALA has partnered with the University of Texas MD Anderson Cancer Center, Houston, for educational initiatives to improve coverage in state Medicaid programs, she added. 

Myrna Godoy, MD, PhD, associate professor, Department of Diagnostic Radiology, MD Anderson, noted it is surprising that there is disagreement over this. “We have two large trials that have shown the benefits of screening and that it is appropriate for high-risk patients,” she told Medscape Medical News. “It is recommended by the Task Force and CMS, and private insurance will reimburse for it, but Medicaid doesn’t for everyone.”That isn’t fair and it should be standardized   Myrna Godoy, MD, PhD

“That isn’t fair and it should be standardized,” she added. “It’s not fair that the same person with the same risk [isn’t covered] just because of their location. Everyone should be able to benefit from screening.”

In December 2013, the USPSTF finalized its recommendations on lung cancer screening for high-risk populations. The recommendation was in-line with those issued by several other bodies, including the American Cancer Society, American College of Chest Physicians, and National Comprehensive Cancer Network. Medicare finalized a National Coverage Determination in February 2015, which reimbursed for LDCT scans in a high-risk population between the ages of 55 and 77.

Medicaid Confusion

Standard Medicaid insurance does not require coverage of USPSTF recommended screenings, and each state can decide how coverage will work, explained Green. Coverage can also vary between fee-for-service and managed care plans within a state’s Medicaid program.

The ALA report only looked at fee-for-service plans and not managed care plans in each state. “So just because the fee-for-service plans don’t cover lung cancer screening, it doesn’t mean that managed care plans aren’t covering it,” she said. “That is another area of research that we need to look at.”

Another variable is Medicaid expansion, which took place under the Affordable Care Act (ACA). Medicaid expansion plans are required to cover preventive services that received an “A” or “B” by USPSTF, which means that lung cancer screening should be covered without cost-sharing for patients with Medicaid expansion.

“States have to provide Medicaid coverage for lung cancer screening, but only for those who entered under the expansion program,” said Green. “So even within a single state, there can be different eligibility criteria.”

In their assessment of Medicaid coverage in the fee-for-service program, the ALA found that eligibility criteria for screening varied considerably. Among states offering coverage, 13 states follow the USPSTF criteria, three states followed the Medicare criteria, and 15 states used other criteria.

In addition, 13 states also required providers to obtain prior authorization before screening will be covered.