- What is breast cancer
- What are the risk factors for breast cancer?
- Breast cancer risk factors you cannot change
- Lifestyle-related risk factors for breast cancer
- Factors with unclear effects on breast cancer risk
- Disproven or controversial breast cancer risk factors
- Can breast cancer be prevented?
- Signs and symptoms of breast cancer
- American Cancer Society recommendations for early breast cancer detection in women without breast symptoms
- Paying for breast cancer screening
- References: Breast cancer prevention and early detection
Paying for breast cancer screening
In the United States, certain laws require most private health plans, Medicaid, and Medicare to cover early detection services for breast cancer screening.
Laws requiring coverage for breast cancer screening
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.
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. Laws on coverage vary slightly from state to state, so check with your insurer to see what’s covered.
Note: State laws don’t affect self-insured (self-funded) health plans.
Insurance coverage for breast cancer screening
Self-insured (self-funded) plans
Many employers offer self-insured (self-funded) plans. These plans pay employee health care costs from the employer’s own funds, even though they usually contract with another company to track and pay claims.
Self-insured or self-funded plans do not have to follow state laws about breast cancer screening. Instead, 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.
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 to find out what breast cancer early detection services are covered.
As a part of the Affordable Care Act, Medicare covers the full cost of a screening mammogram once every 12 months for all women with Medicare aged 40 and over. Diagnostic mammograms are covered with a 20% co-pay after the part B deductible is met.
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 give you details about screening coverage in your state.
National Breast and Cervical Cancer Early Detection Program
States are making breast cancer screening more available to medically underserved women through the Centers for Disease Control and Prevention’s (CDC’s) 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:
- Diagnostic testing for women whose screening results are abnormal
- Surgical consultations
- Referrals to treatment
Each state’s Department of Health will have information on how to contact the nearest NBCCEDP screening and early detection program in your area. To learn more, contact the CDC at 1-800-CDC-INFO (1-800-232-4636) or online at www.cdc.gov/cancer/nbccedp.
We have a lot more information you might find helpful. You can read more online or call one of our cancer information specialists at 1-800-227-2345 any time, day or night.
Last Medical Review: 10/09/2015
Last Revised: 10/20/2015