Breast Cancer Early Detection

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Paying for breast cancer screening

This section gives a brief overview of the laws that require private health plans, Medicaid, and Medicare to cover early detection services for breast cancer screening.

Federal law

Coverage of mammograms for breast cancer screening is mandated by the Affordable Care Act, which provides that these be given without a co-pay or deductible in plans that started after August 1, 2012. This doesn’t apply to health plans that were in place before the law was passed (called grandfathered plans). You can find out the date your insurance plan started by contacting your health insurance plan administrator. Even grandfathered plans may still have coverage requirements based on state laws, which vary, and other federal laws.

State efforts to ensure private health insurance coverage of mammography

Many states require that private insurance companies, Medicaid, and public employee health plans provide coverage and reimbursement for specific health services and procedures. The American Cancer Society (ACS) supports these kinds of patient protections, particularly when it comes to evidence-based cancer prevention, early detection, and treatment services.

The only state without a law ensuring that private health plans cover or offer coverage for screening mammograms is Utah (see table below). Of the remaining 49 states that have enacted either assured benefits or ensured offerings for mammography coverage, many states do not conform to ACS guidelines and are either more or less “generous” than ACS recommendations. Some states like Rhode Island, however, specifically state in their legislative language that mammography screening should be covered according to the ACS guidelines.

State mammography screening coverage laws

    State

    Frequency and age requirements*

 

    Alabama

    Every 2 years for women in their 40s or physician recommendation; each year for 50+, or physician recommendation

    Alaska

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Arizona

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Arkansas

    Insurers must offer coverage for baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    California

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Colorado

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Connecticut

    Baseline for ages 35-39, every year 40+

    (Individual and group insurers are also required to provide coverage for a comprehensive ultrasound screening of the entire breast if it is recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under the American College of Radiology’s Breast Imaging Reporting and Data System.)

    Washington, DC

    Coverage

    Delaware

    Baseline for ages 35-39, every 2 years for 40s, each year 50+

    Florida

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Georgia

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Hawaii

    Annual for 40+, or physician recommendation

    Iowa

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Idaho

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Illinois

    Baseline for ages 35-39, annual for 40+

    Indiana

    Insurers must offer coverage for Annual for 40+, or physician recommendation

    Kansas

    Covered in accordance with American Cancer Society guidelines if insurers provide reimbursement for lab and X-ray services

    Kentucky

    Baseline for ages 35-39, every 2 years for 40s, each year 50+ (some plans exempt)

    Louisiana

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation (some plans exempt)

    Massachusetts

    Baseline for ages 35-39 and annual for 40+

    Maryland

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation (some plans exempt)

    Maine

    Annual for 40+

    Michigan

    Insurance must offer or include coverage of baseline for ages 35-39, annual for 40+

    Minnesota

    If recommended (some plans exempt)

    Missouri

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Mississippi

    Insurance must offer annual for ages 35+

    Montana

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    North Carolina

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    North Dakota

    Baseline for ages 35-39, annual for 40+, or physician recommendation.

    Nebraska

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    New Hampshire

    Baseline for ages 35-39, every 2 years for 40s, each year 50+ (some plans may be exempt)

    New Jersey

    Baseline for ages 35-39, each year for 40+ (some plans exempt)

    New Mexico

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Nevada

    Baseline for ages 35-39, and annual for 40+

    New York

    Baseline for ages 35-39, every year for 40+, or physician recommendation

    Ohio

    Baseline for ages 35-39, every 2 years for 40s, every year if a woman is at least 50 but under 65, or physician recommendation

    Oklahoma

    Baseline for ages 35-39, and annual for 40+

    Oregon

    Annual for 40+, or by referral

    Pennsylvania

    Annual for 40+, physician recommendation. for under 40

    Rhode Island

    According to ACS guidelines

    (Also requires individual and group insurers to provide coverage for 2 screening mammograms per year for women who have been treated for breast cancer within the past 5 years or who are at high risk for developing cancer due to genetic predisposition, have a high-risk lesion from a prior biopsy or atypical ductal hyperplasia)

    South Carolina

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation, in accordance with American Cancer Society guidelines

    South Dakota

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Tennessee

    Baseline for ages 35-39, every 2 years for 40s, each year 50+, or physician recommendation

    Texas

    Annual for 35+

    Utah

    None

    Virginia

    Baseline for ages 35-39, every 2 years for 40s, each year 50+ (some plans exempt)

    Vermont

    Annual for 50+, physician recommendation for under 50

    Washington

    If recommended

    Wisconsin

    Two exams total for ages 45-49, each year 50+

    West Virginia

    Baseline for ages 35-39, every 2 years for 40s

    Wyoming

    Covers a screening mammogram and clinical breast exam along with other cancer screening tests; however, the health plan is responsible only up to $250 for all cancer screenings

*Laws on coverage may vary slightly from state to state, so check with your insurer to see what’s covered. Note that state laws don’t affect self-insured (self-funded) health plans.

Sources: Health Policy Tracking Service, “Mandated Benefits: Breast Cancer Screening Coverage Requirements,” 4/01/04; CDC Division of Cancer Prevention and Control “State Laws Relating to Breast Cancer: Legislative Summary, January 1949 to May 2000.”
Health Policy Tracking Service, “Overview: Health Insurance Access and Oversight,” 6/20/05
Netscan’s Health Policy Tracking Service Health Insurance Snapshot, 8/8/05
Netscan's Health Policy Tracking Service, “Mandated Benefits: An Overview of 2006 Activity,” 4/3/06
Updated 9/14/06, ACS National Government Relations Department
Hanson K, Bondurant E. National Council of State Legislatures, “Cancer Insurance Mandates and Exemptions.” August 2009. Accessed at www.ncsl.org/portals/1/documents/health/CancerMandatesExcept09.pdf on August 24, 2012

Other state efforts and self-insured plans

Other types of health coverage also provide screening mammograms. Public employee health plans are governed by state regulation and legislation, and many cover screening mammograms.

Self-insured or self-funded plans do not have to follow state laws about breast cancer screening. They are governed by the Affordable Care Act (ACA), and are required to cover breast cancer screening. The exception is any self-insured plan that was in effect before the ACA was passed. These plans are called grandfathered, and they don’t have to provide coverage based on what the ACA says.

Self-insured plans are often larger employers which pay employee health care costs from their own funds, even though they usually contract with another company to track and pay claims. You can find out if your health plan is self-insured by contacting your insurance administrator at work or reading your Summary of Plan Benefits. Women covered by self-insured employer plans should check with their health insurance administrator to see what breast cancer early detection services are covered.

Medicaid

All state Medicaid programs plus the District of Columbia cover screening mammograms. This coverage may or may not conform to American Cancer Society guidelines. State Medicaid offices should be able to provide screening coverage information to interested individuals. The Medicaid programs are governed by state legislation and regulation, so assured coverage is not always apparent in legislative bills.

In addition, all 50 states plus the District of Columbia have opted to provide Medicaid coverage for all women diagnosed with breast cancer through the Centers for Disease Control and Prevention’s (CDC’s) National Breast and Cervical Cancer Early Detection Program (see the next section), so that they may receive cancer treatment. This option allows states to receive significant matching funds from the federal government. States vary in the age, income and other requirements that women must meet in order to qualify for treatment through the Medicaid program. (All 50 states, 4 U.S. territories, the District of Columbia, and 13 American Indian/Alaska Native organizations participate in the National Breast and Cervical Cancer Early Detection Program.)

National Breast and Cervical Cancer Early Detection Program

States are making breast cancer screening more available to medically underserved women through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The NBCCEDP attempts to reach as many women in medically underserved communities as possible, including older women, women without health insurance, and women who are members of racial and ethnic minorities. Age and income requirements vary by state.

The program provides both screening and diagnostic services to low-income, uninsured, and underserved women for free or at very low cost, including:

  • Clinical breast exams
  • Mammograms
  • Pap tests
  • Diagnostic testing for women whose screening results are abnormal
  • Surgical consultations
  • Referrals to treatment

Though the program is administered within each state, tribe, or territory, the Centers for Disease Control and Prevention (CDC) matches funds and support to each program.

Since 1991 when the program began, it has provided millions of screening exams to underserved women and diagnosed more than 50,000 breast cancers. Due to limited resources, though, less than 1 in 8 eligible women aged 40 to 64 is able to be screened for breast cancer through this program nationwide.

In 2000, Congress passed the Breast and Cervical Cancer Prevention and Treatment Act, giving states the option to offer women in the NBCCEDP access to treatment through Medicaid. All 50 states plus the District of Columbia provide Medicaid coverage for women diagnosed with breast cancer through the NBCCEDP, so that they have a way to pay for treatment.

Each state’s Department of Health will have information on how to contact the nearest CDC screening and early detection program in your area. For more information, please contact the CDC at 1-800-CDC-INFO (1-800-232-4636) or through their website at www.cdc.gov/cancer.

Medicare

As a part of the Affordable Care Act, Medicare covers the full cost of a mammogram once every 12 months for all women with Medicare aged 40 and over. (Women are eligible for Medicare if they are age 65 and older, are disabled, or have end-stage renal disease.) Medicare also pays for a clinical breast exam when it is done for screening or prevention.


Last Medical Review: 09/17/2013
Last Revised: 01/28/2014