Possible Loss of Screening Coverage Will Impact Radiology Practices

In April, 2020, the Federal Medical Assistance Percentage (FMAP) was increased so that states would receive extra funding for their Medicaid programs in support of the COVID-19 public health emergency. In exchange, the states promised to pause Medicaid eligibility checks so that more people would be able to continue to receive Medicaid benefits to get through the pandemic.

Not all states went along with the FMAP increase program, but those that did saw significant increases in Medicaid enrollment. For example, in New Jersey there were 1.4 million people enrolled in Medicaid just before the pandemic hit (February 2020) and by July 2023 that figure had increased to over 2 million enrollees. Radiology practices benefit when more of their patients have coverage.

Beginning in April 2023, states were able to resume eligibility checks and terminate individuals who were no longer eligible. As a result, Medicaid enrollment began to decline so that by May 2024, enrollment in New Jersey was down 17% to 1.7 million. Many of those who lost Medicaid coverage moved over to insurance plans available from the Affordable Care Act (ACA) Exchange. They were able to do so in part due to ACA premium subsidies available under the American Rescue Plan. Those premium subsidies are due to expire at the end of 2025.

Since the ACA contains a mandate that insurers cover preventive services such as mammography screening, lung cancer screening, and CT colonography without cost-sharing by beneficiaries, former Medicaid patients moving to the ACA plans will continue to be able to obtain these critical services. However, an appeals court decision in June 2023 has thrown ACA screening coverage into question and could potentially eliminate screening coverage for millions of Americans. The federal Justice Department has filed a petition requesting the Supreme Court review the ruling.

If it is upheld, the appellate court’s decision will significantly impact radiology by reducing the number of people who are able to afford themselves of screening at no out-of-pocket cost. The implications extend beyond radiology to other specialties, as there are at least 16 services that would no longer be required to be covered without cost-sharing by ACA insurance plans.

Both the loss of the ACA premium subsidies and the loss of screening availability under the ACA would cut into radiologists’ flow of patients beginning no later than the end of 2025 but possibly sooner. We will continue to monitor these situations as they develop. Subscribe to this blog for all the latest information that will affect your practice’s reimbursement.

Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.

Related Articles

Medicare Finalizes 2025 Fee Schedule Cut

What Else is in the Medicare Proposed Rule for 2025?

Medicare Proposed Rule Again Cuts Radiology Reimbursement in 2025