The 2022 ACA Rule: Your Colonoscopy Should Still Be Free Even If They Remove a Polyp

If you got a bill after a “free” screening colonoscopy in 2023 or later, your insurer may owe you a refund.

For years, one of the most common — and most infuriating — colonoscopy billing traps worked like this: your insurer told you a screening colonoscopy was covered at $0. You scheduled it. The doctor found and removed a small polyp (which happened in your favor — that’s the whole point of the screening). Then three weeks later, a $600–$1,500 bill arrived. Your insurer had reclassified the procedure from “preventive” to “diagnostic” the moment a polyp was removed, wiping out your $0 cost protection.

It was legal. It was widely practiced. It infuriated patients and gastroenterologists alike.

In 2022, federal regulators fixed it.

What the 2022 Rule Actually Says

Effective for plan years beginning on or after May 31, 2022, a federal rule issued under the Affordable Care Act requires that:

When a polyp is found and removed during what was scheduled as a screening colonoscopy, the entire procedure — including the polypectomy — must be treated as a preventive service covered at $0 cost-sharing for the patient.

The underlying logic: if you can’t remove a polyp without losing your $0 coverage, you’re effectively being penalized for getting the most out of a preventive screening. That creates a perverse incentive for doctors not to remove suspicious tissue during the same session. The 2022 rule closes that loophole.

The KFF (Kaiser Family Foundation) estimated in 2021 that approximately 1.2 million people per year were receiving unexpected bills after polyp removal during screening colonoscopies — a problem the rule was specifically designed to eliminate.

Which Plans Are Covered

The Self-Insured ERISA Exception — Check With HR

Self-insured employer plans (where the employer bears the financial risk rather than an insurance company) are governed by federal ERISA law, not ACA regulations. Many self-insured plans voluntarily comply with ACA preventive care requirements, but they’re not legally mandated to do so under the 2022 rule.

A 2023 Supreme Court ruling (Braidwood Management v. Becerra) created additional legal uncertainty around whether ACA preventive care mandates apply to self-insured plans at all. As of 2026, this remains contested, and some self-insured plans have stopped covering certain preventive services at $0.

What to do: If you have employer-sponsored coverage, ask HR or your benefits administrator: “Does our plan follow the 2022 ACA rule on colonoscopy polypectomy cost-sharing?” Get the answer in writing before your procedure.

How to Tell If Your Plan Is Grandfathered

A grandfathered plan is one that was in place on March 23, 2010, the date the ACA was signed, and has not made substantial changes since. If your plan is grandfathered, it’s required to notify you. Check your plan documents, Summary of Benefits and Coverage, or annual enrollment materials — grandfathered status must be explicitly disclosed.

Most employer plans have changed enough since 2010 that they’ve lost grandfathered status. If your plan documents don’t say “grandfathered,” your plan almost certainly isn’t.

What Happened to Your Bill: Common Coding Scenarios

When a polyp is removed during a screening colonoscopy, the procedure code changes. The original CPT code for a routine screening is 45378. When a polyp is removed, it typically becomes:

• CPT 45380 (colonoscopy with biopsy)
• CPT 45385 (colonoscopy with polypectomy by snare technique)

Under the old (pre-2022) system, this code change automatically triggered a reclassification to “diagnostic” in many insurers’ systems — flipping cost-sharing from $0 to your deductible/coinsurance. Many insurers’ systems weren’t updated promptly after the 2022 rule, meaning patients continued receiving wrong bills into 2023 and 2024.

How to Appeal a Wrong Colonoscopy Bill

If you received a bill after a screening colonoscopy where a polyp was removed, and your plan should be covered by the 2022 rule, here’s how to dispute it:

Step 1: Get your Explanation of Benefits (EOB) from your insurer. Confirm how the claim was processed and what reason code was used for the cost-sharing.

Step 2: Call your insurer’s member services line. Ask: “My screening colonoscopy was reclassified to diagnostic after polyp removal. I believe the 2022 ACA preventive care rule requires this be processed at $0. Can you confirm my plan’s compliance with that rule and reprocess the claim?”

Step 3: If they resist, file a formal internal appeal. Reference the specific rule: the Department of Health and Human Services interim final rule effective for plan years beginning on or after May 31, 2022 (published in the Federal Register, 87 FR 52614).

Step 4: Escalate to your state insurance commissioner if the appeal is denied and your plan is fully-insured (not self-insured). Your state’s Department of Insurance can investigate improper claim processing.

Step 5: File a complaint with CMS for ACA marketplace and compliant employer plans at healthcare.gov/marketplace-appeals/.

A Note on Pathology — the One Exception

The 2022 rule covers the colonoscopy procedure itself and the polypectomy performed during it. It does not automatically cover the pathology/lab fee charged when the removed polyp tissue is analyzed. Pathology is billed separately by the laboratory, and it’s subject to your normal plan cost-sharing (deductible, coinsurance).

That pathology bill — typically $100–$400 — is legitimately your responsibility under most plans. It’s annoying but correct. If you receive a separate facility/physician bill for the colonoscopy itself, that’s the one to dispute.

Bottom Line

The 2022 rule is a genuine patient protection that closed a widely-complained-about billing gap. For the vast majority of commercially insured Americans on ACA-compliant plans, a screening colonoscopy where a polyp is found and removed should cost you exactly the same as one where nothing is found: $0. If your insurer sent you a bill anyway, the tools above will help you get it reversed.